HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 16 CARLTON LANE 6/11/2021 Commonwealth of Massachusetts rECEIVED
City/Town of No. Andover
,1�1,� 1 1 2021
System Pumping Record
TQ�NN OF NORTH ANDO",
Form 4
M HrAOi 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 16 14hr lei? 0
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
rab
Name
ienrn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record 100 t)
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) �eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes;Z/No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
C
6. System X::�
d By:
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
ature �aul ��� Date
Same day
Signature of Receiving Facility(or attach facility receipt) Date
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