HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 170 OLYMPIC LANE 10/7/2021 Commonwealth of Massachusetts RECEIVED
City/Town of No Andover OCT 0 7 7pZ1
System Pumping Record TOWN OF NORTH ANDOVER
y p g HEALTH DEPARTMENT
Form 4
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 L
key to move your Address
cursor-do not No Andover MA
use the return City/Town State Zip Code
key.
2. System Owner:
Name
remsn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record 00
1. Date of Pumping Date 2 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Ye No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped�2WD
6. Syst mped By:
'b
Name— Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 St.,Bradford,MA J
Aa
Signat r auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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