HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 72 GRAY STREET 5/5/2022 Commonwealth of Massachusetts AECEIVEL'
City/Town of No.Andover MAY 0 5 2022
System Pumping Record
Y p g
Y Form 4 TOWN OF NORTH ANDOVER
„ HEA!-TH 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,
use only the tab 221— 5�
key to move your Address
cursor-do not
use the return City/Town State Zip Code
key.
r�
2. System Owner:
Name
iertan
Address(if different from location)
No. Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record -7
1. Date of Pumping Date l u 2. Quantity Pumped: `t 00Q
allons
3. Component: ❑ Cesspool(s) [;� Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [y/No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
J W0
6. System Pumped By:
/VIagg-r�
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 at
Signature-of Facility(or attach facility receipt) Date
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