HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 660 GREAT POND ROAD 5/5/2022 8ECEIVEL-
Commonwealth of Massachusetts SAY p 5 2022
City/Town of No.Andover
iRl System Pumping Record TC',VN OF NORTH ANDOVEP
y p g HEALTH DEPARTMENT
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 InforrPation
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return Cityrrown State Zip Code
key.
2. System Owner: ` /
Name
renen
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
5 Od
1. Date of Pumping Dat6 Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes VINO If yes, was it cleaned? ❑ Yes ❑ No
5. Observed conditionof component pumped:
6. System Pumped
Name Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill St ,Bradf d,M
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1