HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1785 SALEM STREET 10/7/2020 Commonwealth of Massachusetts RECEIVED
W City/Town of No. Andover
System Pumping Record OCT 0 7 2020
Form 4 TOWN OF NORTH ANDOVER
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 I-7 8�
Important:When /
filling out forms 1. System Location:
on the computer,
use only the tab ,
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
�1 2. System Owner:
Name
iensn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping :Septic
Quantity Pumped:Date Gallons
3. Component: ❑ Cesspool(s) 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 compoDept pumped: l(
6. Sys Pumped By:
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were dispose
0 S . Mill St., radford, MA
� D
� r
ignature o Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11112 System Pumping Record•Page 1 of 1