HomeMy WebLinkAbout- Septic Pumping Slip - 50 STANTON WAY 2/3/2022 RECEIVED
Commonwealth of Massachusetts
F City/Town of No. Andover FEB 0 3 2022
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH 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: `C"�G✓ /) (/V
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:
Name
rsnan
Address(if different from location)
No. Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping D to 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Ye1KNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
L�1-G
6. System P 7ped B
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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