HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 51 STANTON WAY 5/19/2020 Commonwealth of Massachusetts RECEIVE®
City/Town of No. Andover MAY 19 2020
System Pumping Record TOWN OF NORTH ANDOVER
Form 4
HEALTH DEPARTEv9ENT
iG^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, 5 S
use only the tab
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System O ner:
� ,( d M
Name
renen
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record /
1. Date of Pumping Date 2, uantity Pumped: Gallons
3. Component: ❑ Cesspool(s) eptic Tank ank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes L-No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of compo t pumped:
6. Syst ed By:
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
St., Bradford, MA
Signature of Haul Date
Signature of Receiving Facility(or attach facility receipt) Date
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