HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 64 STANTON WAY 11/23/2020 IC
Commonwealth of Massachusetts RECEIVE®
W City/Town of No. Andover
Nov 2 3 Lu'u
a 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, 6V ,n
use only the tab
key to move your Address
cursor-do not No. Andover M
use the return —
key. City/Town State Zip Code
2. System Owner:
I&Lkl
rah
Name - ------ - --
Teem
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ate l 2 uantity Pumped: Gallons3. Component: [ICesspool(s) eptic 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 compQn ent pumped:
6. Syst m umped By:
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 Sa ill St., Bradfor :MA
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1