HomeMy WebLinkAboutSludge Tank - Septic Pumping Slip - 351 WILLOW STREET 12/7/2020 Commonwealth of Massachusetts ``" t-
City/Town of No. Andover DEC 0 ? 2020
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 Hr4,'TH^[71,77 'ENT
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, 3� �' II(J ('�
use only the tab / J
key to move your Address
cursor-do not No. Andover MA 01845
use the return Ci !town
key. ty State Zip Code
2. System Owner:
Name
renrn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
-2-�
1. Date of Pumping 23
Date I , 2. Quantity Pumped: Gallons
A7
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
s>�
R Other(describe): — `
4. Effluent Tee Filter present? ❑ Yes ET No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed co dition of component pumped:
6. S�`ys'tem Pumpeq6y�--
JaY
NameVehicle License Number
Stewart's Septic 58 So. Kimball St. Bradford MA
Company
7. Location where contents were disposed:
20 So. Mill St., Bradford, MA
r Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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