HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 54 LONG PASTURE ROAD 5/19/2020 Commonwealth of Massachusetts
W City/Town of No. Andover MAY 19 Zn,,
System Pumping Record TOWN OFNORTFiAt4�Gw__
Form 4 HEALT;; -
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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, CL/ Q
use only the tab J / po l
key to move your Address
cursor-do not No. Andover MA 01845
use the return Cityrrown State Zip Code
key.
2. System Owner:
Oa S/veirvt
Name
ream
Address(if different from location)
Cityfrown State Zip Code
Telephone Number
B. Pumping Record
�'-13 -- zo � J
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) F' Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? e/Yes ❑ No If yes, was it cl aned? Yes ❑ No
5. Observed condition of component pumped: ��
6. S tem PumVYZA'� V&,'
_
ame Vehicle License Number
StewarCs Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill St., Brad rd, MA
01 -
'fignalare'6f—Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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