HomeMy WebLinkAboutSludge Tank - Septic Pumping Slip - 351 WILLOW STREET 12/10/2019 (2) �L\ Commonwealth of Massachusetts RECEIVED
W City/Town of No. Andover DEC 10 2019
} System Pumping Record TOWN OF NORTH ANDOVER
Form 4 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,
use only the tab 5,�P tNi((6W S�
key to move your Address ---
cursor-do not No. Andover
use the return MA 01845
key. City/Town State
Zip Code
2. System Owner:
nem
Address(if different fr—om location) —
City/Town State
Zip Code
Telephone Number
B. Pumping Record =-
1. Date of Pumping Date/ 2. Quantity Pumped: 57
GdIlons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe): _--
4. Effluent Tee Filter present? ❑ Yes aVo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. S m Pumped B :
10
Gg
e �Vehicle License Number
Stewart's Septic 58 So. Kim Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill St., B dford, MA
Sig lure of Hauler Date
S' nature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11112
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