HomeMy WebLinkAboutPump Chamber - Septic Pumping Slip - 643 TURNPIKE STREET 11/23/2020 Commonwealth of Massachusetts RECEIVED
H W City/Town of No. Andover
a
System Pumping Record NOV 2 3 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 CM 15.351.
A. Facility Information
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.
2. System Owner:
r� C"n't.�O _
Name
ream
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 01 ��T � 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ErTight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ��o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of componen pump
i j C c:>
jG 7/- C,f j® el �� S
6. Syst mped By: �--�
Name l Vehicle License IJumber
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20So, Mill St., Bradford, MA
u re Date
Signature of Receiving Facility(or attach facility receipt) Date
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