HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 260 SUMMER STREET 8/11/2020 Commonwealth of Massachusetts RECEIVED
City/Town of No. Andover ?O20
System Pumping Record VER
y p g TOWN OF NURTH ANUU
Form 4 HEALTH DEPARTMENT
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, ( S�use only the tab
key to move your Address
cursor-do not No. Andover MA 01845
use the return
key. Citylrown State Zip Code
2. System Owner:
VILA
Name
ream
Address(if different from location)
City/'Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Q ntity Pumped:
Date Gallons
3. Component: ElCesspool(s) � eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): --
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of compone t;lmped:
6. S st m ped By: aft
�-
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford MA
Company
7. Location where contents were dispo
20 111 St., dford, MA
Signs ure o Haule Date `
Signature of Receiving F ity(or attach facility receipt) Date
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