HomeMy WebLinkAbout- Septic Pumping Slip - 414 SUMMER STREET 5/5/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of No.Andover MAY 0 5 2022
=' System Pumping Record RTHANDOVER
Form 4 ;t=NO
TGH.EALTH 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:
on the computer, q/(� �jl � �1
use only the tab _/
key to move your Address
cursor-do not
use the return City/Town State Zip Code
key.
vsA2. System Owner:
rab
Name
Address(if different from location)
No. Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record 44 1. Date of Pumping 2. QuantityPumped: /Sno
p g Date um p Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present�Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
cis►
6. Sys ed By:
Name 4Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
0 ill St.,Bradford,MA
Sign ure o r Date
Signature of Receiving Facility(or attach facility receipt) Date
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