HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 174 INGALLS STREET 12/10/2019 a
Commonwealth of Massachusetts RECEIVED
W City/Town of No. Andover
System Pumping Record UEC 10 2019
Form 4 ` OWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, Q
use only the tab 17 qqS (�
key to move your Address `
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
ft c /a/v
Name
yearn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record _---_----- - ___
1. Date of Pumping Datel ? 2. Quantity Pumped: Gallons�
3. Component: ❑ Cesspool(s) DiSeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of componen pumped:
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill St., Bradfo , MA
t
Signature of Haule—ri7i Date
Signature of Receiving Facility(or attach facility receipt) Date
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