HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 149 SUMMER STREET 4/23/2020 RECEIVED
Commonwealth of Massachusetts APR 9 �p?p
W City/Town of No. Andover
WN OF NORTH
System Pumping Record T�HEALLTHDEPARTMENT ANDOVER
Form 4
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 cation}-1
on the computer, C )))I j C
use only the tab V
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owne
Name - — ---- --_ -
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping _1-3~2-d 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) 9-3eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): --
4. Effluent Tee Filter present? ❑ Yes U5,1qo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumpe
Name IV I Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where co s ere disposed:
20 So. Mill S Bradford, MA
SignatW Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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