HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 65 STANTON WAY 5/19/2020 Commonwealth of Massachusetts ' CiVE®
�;MMXEM City/Town of No. Andover MAY 19 2 0
System Pumping Record
Form 4 TOWN OF NURTHANDUVER
HEALTH DEPART'�;E�;T
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?Lcatiom /
on the computer, Sim
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. Sysr Owner:
Name
rim
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record /
1. Date of Pumping Date 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 comp�mped:
6. System P ed By:
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were dispose
2 o Mill S ., Bradford, M
Signat re o Haul Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1