HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 223 FOREST STREET 11/23/2020 Commonwealth of Massachusetts
W City/Town of No. Andover RECEIVED
System Pumping Record NOV 2 3 z020
Form 4
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Other forms r I> wi 9 jW[;e
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 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 Record16 ho
Date of Pumping Date zSeptic
uantity Pumped:
allons
3. Component: ❑ Cesspool(s) ank ❑ Tight Tank ❑ 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. System Pumped By:
7:1k- f�f LA)
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Br_adford,MA
Company
7. Location where contents were disposed:
20 So. Mill St.—Bradford, MA
J0 /G _A0
Si auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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