HomeMy WebLinkAboutSepitc Tank / pump chamber - Septic Pumping Slip - 1062 SALEM STREET 5/5/2022 Commonwealth of Massachusetts RECEIVED
City/Town of No.Andover MAY 0 5 2022
System Pumping Record
e % Form 4 TG`.`vl'.I OF NORTH ANDOVER
;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 CM 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, /h �) _
use only the tab /(1 (Y
key to move your Address
cursor-do not
use the return City/Town State Zip Code
key.
r�
2. System Owner:
Gyci /2u0"/-
Name
ienm
Address(if different from location)
No. Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date' 2. Quantity Pumped: Gallon OQ 3. Compo ent: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe): iot) Chi ,
4. Effluent Tee Filter present? ❑ Yes ZNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pum ed By:
Name Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill S adforLWA
Signatur auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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