HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 201 RALEIGH TAVERN LANE 1/19/2022 RECEIVED
Commonwealth of Massachusetts JAN 192022
City/Town of No. Andover TOWN OF NORTH ANDOVER
a HEALTH DEPARTMENT
System Pumping Record
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 ;k Ig);I-A
dC/
key to move your Address
cursor-do not
use the return City/Town State Zip Code
key.
2. System Owner: '&111,—L
Name
ream
Address(if different from location)
No. Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Da a 2. Quantity Pumped: Ga ons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 51�"No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped'.
6. System P By D
Name Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill S Bradford,MA p�
Si re of Hauler Dat 1t� v /'-7
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1