HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 21 APPLETON STREET 10/7/2020 � Commonwealth of Massachusetts RECEIVED
City/Town of No. Andover OCT 0 7 2020
System Pumping Record
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 tabMC-1 —_
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
dpple,� - -
Name
rim
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date - 2. Quantity Pumped: Gauo s
3. Component: ❑ Cesspool(s) �eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -- -- ----- -
4. Effluent Tee Filter present? ❑ Yes 01�No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. Sy\ mped By:
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford MA
Company
7. Location where contents were disposed:
20 : ill St., &ord, MA
Si au r Date
Signature of Receiving Facility(or attach facility receipt) Date
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