HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1220 SALEM STREET 6/22/2020 Commonwealth of Massachusetts RECEIVED
W City/Town of No. Andover
System Pumping Record JUN 2 2 202u
Form 4 TOWN OF NORTH ANDUvER
HEALTH DEPARTMENT
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, U vl /1�use only the tab U T,
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
r�
2. System Owner:
Name r/
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Q ntity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes �Olf yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component umped:
6. Syste m ed By: /
Vehicle License Number
StewarYs Septic 58 So. Kimball St., Bradford,MA
Company
7. where contents were disposed:
20 S ill S , Brad , MA
atur o uler Date
Signature of Receiving Facility(or attach facility receipt) Date
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