HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 31 OXBOW CIRCLE 11/23/2020 IC
Commonwealth of Massachusetts
City/Town of No. Andover RECEIVED
System Pumping Record 102U
Form 4 NOV 2 3
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Other forms may bed �rrt tneMENT
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, �31 oxboyo j
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:
t� Fewn
Name
seem
Address(if different from location)
City/Town State Zip Code
Telepho-n
' B. Pumping Record
11 p�
1. Date of Pumping 'D�26 w Quantity Pumped:
Date Gallons
3. Component: ElCesspool(s) Septic Tank ❑ 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:
0
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. t., Bradford, MA
re r Dam
Signature of Receiving Facility(or attach facility receipt) Date
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