HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 43 CHRISTIAN WAY 12/10/2019 Commonwealth of Massachusetts RECEIVED
W City/Town of No. Andover
DEC 10 2019
System Pumping Record
1 Form 4 TOWN OF NORTH ANDUVER
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. Syste Location.
on the computer,
use only the tab �14
key to move your Add ss
cursor-do not No. Andover MA 01845
use the return Cityrrown State Zip Code
key.
2. System caner:
Name ,
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped. Gallons
3. Component: ❑ Cesspool(s) /eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a'No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped.
C.70z 4
6. SysteTrPlumped By.
Name Vehicle License Number
StewarCs Septic 58 So. Kimb II St., Bradford,MA
• Company
7. Location where contents were disposed:
20 to. Mill St., Brad rd, M
jSinre of Hauler Date
re of Receiving Facility(or attach facility receipt) Date
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