HomeMy WebLinkAboutSeptic Tank & Pump Chamber - Septic Pumping Slip - 20 ROSEMONT DRIVE 1/19/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of No. Andover BAN 19 2022
System Pumping Record TOWN OFrdORj NTT
HANDO
Form 4 HEALTH DEPART ME
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
key to move your Address
cursor-do not
use the return City/Town State Zip Code
key.
2. System Owner:
res
Name
�aam
Address(if different from location)
No. Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record �2
1. Date of Pumping Date 2. Quantity Pumped: Gallons 56
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): �Lkff avl'
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
coo
6. System Pumped By:
Name Vehicle License Number
Stewart's Ztic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill St adfor A
/Z F z
natur f Haule Date
ignature of Receiving Facility(or attach facility receipt) Date
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