HomeMy WebLinkAboutPump Chamber - Septic Pumping Slip - 370 GREAT POND ROAD 4/23/2020 Commonwealth of Massachusetts RECEIVED
W City/Town of No. Andover APR g 2020
System Pumping Record TOWN OF NORTH MDUVER
Form 4 HEALTH DEPARTM
�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. Syste I ^v'atlon:
on the computer,
use only the tab V rr 444
key to move your Address
cursor-do not No. Andover MA 01845
use the return Cityrrown State Zip Code
key.
2. System wner:
rah
Nam _
ream
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping e ( � / 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped B fJ /
�f u�c S ✓�
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So Mill t., Br ford, ,)
��J
Si nature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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