HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 15 LONG PASTURE ROAD 11/23/2020 Commonwealth of Massachusetts
W City/Town of No. Andover RECEIVED
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 CMR 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
use the return Cit /Town State Zip Code
key. City
Frown
System Owner:
reb / i
Name -
ream
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
(y' — , 00
1. Date of Pumping Date ^/ . Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ZNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. Syste`L. umped By:
�!�- EAje - —
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill radford, MA
0—/ '��
Wtuofauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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