HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 41 BRUIN HILL ROAD 11/23/2020 Commonwealth of Massachusetts RECEIVED
City/Town of No. Andover NOV 2 3 Mu
System Pumping Record
OF NORTH
Form 4 TOWN HEALTHDEPARTM NTER
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, 1�1, `� r �d,
use only the tab I' cal
key to move your Address
cursor-do not No. Andover MA
use the return
key. City/Town State Zip Code
�1 2. System Owner:
WdA o-V-N
Name
emn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
16
1. Date of Pumping Date 2. ntity Pumped: Galloi s
3. Component: ❑ Cesspool(s) ;--Septictic
Tank ❑ Tight Tank -1 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. Sys m mped
733
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 S . Mill S . Bradford, MA
Sign ture of Hau / Date
Signature of Receiving Facility(or attach facility receipt) Date
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