HomeMy WebLinkAboutSeptic tank - Septic Pumping Slip - 70 SUMMER STREET 7/7/2021 RECEIVED
<�N_ Commonwealth of Massachusetts JUL 0 7 2021
W City/Town of No. Andover TOWN pF NORTH ANot
System Pumping Record HEALTH DEPARTMENT
Form 4
G M
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 CM 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, SIiVl r1_1 ely
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:
Name — - -
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record - �—- - -
1. Date of Pumping Z 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) 211 Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): jN0
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
I Qav�/ SOIIh� (
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill St., Bradford, MA _
Signature of Hauler Date
Same day
Signature of Receiving Facility(or attach facility receipt) Date
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