HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 30 WINDKIST FARM ROAD 6/7/2022 RECEIVED
�L\ Commonwealth of Massachusetts
lgatlagMW City/Town of No. Andover JUN 0 7 2022
System Pumping Record TOWN OF NORTH ANDOVER
r o Form 4 HEALTH DEPARTMENT
�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 5o ("f/j M 'y�l S l �
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
HoSsc�h
Name
rmm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping � �� 2. Quantity Pumped: `� ��
Date Gallons
3. Component: ❑ Cesspool(s) 'Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 2/No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped RB
Q I �.
Name Vehicle License Number
J&S Development Corp. d/b/a
Stewart's Septic Service, 58 So. Kimball St.,
7. Location where contents were disposed:
Stewart's Global.environmental, LLC, 20 So. Mill St., Bradford, MA 01835
Same day
S 're of r Date
Same day
Signature of Receiving Facility(or attach facility receipt) Date
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