HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 2230 TURNPIKE STREET 8/9/2021 IL
Commonwealth of Massachusetts
u W City/Town of No. Andover
System Pumping Record RECEIVED
Form 4 AUG 0 G 2021
DEP has provided this form for use by local Boards of Health. Other f t lid NORTH ANDUVER 4"gNJ)ut the
information must be substantially the same as that provided here. Befol'd>Ising 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, U
use only the tab
key to move your Address
cursor-do not No. Andover MA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
rah
Name - ---- -
�n
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
Uy
1. Date of Pumping Date Z ( 2. Quantity Pumped:
3. Component: ❑ Cesspool(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:
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
Signature of Receiving Facility(or attach facility receipt) Date
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