HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 284 BRADFORD STREET 6/7/2022 Commonwealth of Massachusetts RECEIVED
r W City/Town of No. Andover JIJN p 7 2022
System Pumping Record
TOWN OF NORTH ANDOVER
Form 4
M 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 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,use only the tab dw
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
Name
renm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dat57' Z
r 22. Quantity Pumped: allons 6
0
3. Component: ❑ Cesspool(s) �epticTank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): — -
4. Effluent Tee Filter present? ❑ Yes L1N0 If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of co(mpoo ent pumped:
�-
6. System Pumped-By:
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:
Stewa GI al E 4 onrnent LLC, 20 So. Mill St., Bradford, MA 01835
JSame day
Sign ture of Hauler Date
Same day
Signature of Receiving Facility(or attach facility receipt) Date
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