HomeMy WebLinkAboutPump Chamber - Septic Pumping Slip - 437 SUMMER STREET 7/7/2021 RECEIVED
Z\_ Commonwealth of Massachusetts JUL 0 7 20
a1 W City/Town of No. Andover
System Pumping Record TOWN HEALTH
DEPARTMENT
ER
Y p � HEALTH DEPARTMENT
Form 4
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 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location: -7
on the computer,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:
rab
Name
nem
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gall ns
3. Component: ❑ Cesspool(s) Z/Septic Tank ❑ Tight Tank ❑ Grease Trap
FI/dther(describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
3o
6. System Purnpled 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
nature of auler Date
Same day
Signature of Receiving Facility(or attach facility receipt) Date
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