HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 851 JOHNSON STREET 4/23/2020 RECEIVED
IL
Commonwealth of Massachusetts
City/Town of No. Andover APR 9 ZO20
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System Pumping Record TOWN OF NORTH ANDOVER
y p g HEALTH DEPARTMENT
Form 4
M
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, �l j
use only the tab _ _ /Y� ✓OVVVtJLVI _.
key to move your Address
cursor-do not No. Andover MA 01845
use the return Cityrrown State Zip Code
key.
2. System Owner:
r� Way
Name
�n
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date —Zo 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) E&.-Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Eg-No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumpe y:
u
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA_
Company
7. Location where contents were disposed:
20 So. Mill St., Bradfor
Signature of 496141er Date
Signature of Receiving Facility(or attach facility receipt) Date
t5forrn4.doc•11/12 System Pumping Record•Page 1 of 1
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