HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1794 SALEM STREET 10/7/2021 Commonwealth of Massachusetts RECEIVED
a City/Town of No. Andover OCi 0
System Pumping Record TOWN OF NORTH ANDOVER
7
Form 4 W-A-T-'J-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: S111t
on the computer, 4 P1use only the tab 1
key to move your Address
cursor-do not 01845
use the return Cityfrown State Zip Code
key.
�1 2. System Owner:
Name
renm
Address(if different from location)
No. Andover
Cityfrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date Z/ 2. Quantity Pumped: UJO
Gallons
3. Component: ❑ Cesspool(s) 21 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:
9odd
6. System Pumped By:
lM(a <C)0
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
(a 2"j q j -
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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