HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 120 CANDLESTICK ROAD 5/5/2022 RECENED
Commonwealth of Massachusetts MAY p 5 2022
City/Town of No.Andover .NORTH p,NoovER
System Pumping Record TG AEALj6DEPAR?MENT
Form 4
M
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 (j'7J (.�✓Yl ( 7) 1
key to move your Address
cursor-do not
use the return City/Town State Zip Code
key.
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2. System Owner:
Name
rerun
Address(if different from location)
No. Andover _ MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
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1. Date of Pumping Date 2. Quantity Pumped: �iions
3. Component: ❑ Cesspool(s) Septic Tank El Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of com onent pumped:
6. Syste Ipp�d By�/
Name `r(/y/' Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill S radford,MA
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i �of uler Date
Signature of Receiving Facility(or attach facility receipt) Date
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