HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 4 LACY STREET 11/23/2020 Commonwealth of Massachusetts RECEIVED
WCity/Town of No. Andover NOV 2 3 iO2U
System Pumping Record TOWN OF NORTHANDOvER
y p g HEALTH DEPARTMENT
Form 4
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 CM 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,use only only the tab
key to move your Address
cursor-do not No. Andover MA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
Name -- — -- --
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): — - --- —
4. Effluent Tee Filter present? ❑ Yes ZeNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed conplition of component pumped:
6. System Pumped
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 o. 61ill St., Wdford, MA
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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