HomeMy WebLinkAboutSludge Tank - Septic Pumping Slip - 351 WILLOW STREET 12/10/2019 (4) Commonwealth of Massachusetts RECEIVED
W City/Town of No. Andover
o System Pumping Record DEC 10 Z019
Form 4 TOWN OF NORTH ANDOVER
GSM
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, �,� 5)'
use only the tab
key to move your Address
cursor-do not No. Andover 01845
use the return MA
key. City/Town State
Zip Code
2. System Owner:
rab II
Name
racin
Address(if different from location) —
City/Town State Zip Code
Telephone Number.
B. Pumping Record
1. Date of Pumping Date 1 I 2 Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
[ji0ther(describe):
4. Effluent Tee Filter present? ❑ Yes G?No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Name -- � Ve_ _. _— —
hicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill St., Brad A
Signature ofVauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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