HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 19 OLYMPIC LANE 7/27/2020 S-N Commonwealth of Massachusetts RECEIVED
a1 City/Town of No. Andover
�m System Pumping Record JUL 2 71020
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Form 4 TOWN OF NORTH ANDOVER
M 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,
use only the tab r
key to move your Address �T
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
Name
renm
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
laid
1. Date of Pumping Date Z2— 2 Quantity Pumped: Galls
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 component pumped:
6. System Pumped f
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 S . W St., Bradf MA
` �� tee. --"!5 -C - -
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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