HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 351 WILLOW STREET 5/19/2020 Commonwealth of Massachusetts RECEIVED
w City/Town of No. Andover MAY 19 2020
Y System Pumping Record
Form 4 TOWN OF NOR(H ANDUVER
M HEALTH DEPART^9ENT
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, / IlVf//6 c(..j 5-1—
use only the tab f
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owner: V/
ffi 60 /n J 0
Name
Address(if different from location)
Cityrrown State Zip Code
Telephone.Number
B. Pumping Record
1. Date of Pumping �--- 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ;;rease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of componen umped:
6. S Pumped By: r
LL-Af) /_2 F/�/ 1-2
N me Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford MA
Company
7. Location where contents were disposed:
20 So,Mill St., Bradford, MA -
Sirn—ature4rRaul Date
Signature of Receiving Facility(or attach facility receipt) Date
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