HomeMy WebLinkAbout- Septic Pumping Slip - 410 FOSTER STREET 6/7/2022 Commonwealth of Massachusetts RECEIVED
W City/Town of No. Andover JUN 0 7 2022
System Pumping Record
T01 7t=NORTH ANDOVER
Form 4 H�A;LTH 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
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
s .6
2. System Owner:
Name
re�rn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Z� 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Ob erved,�ndition of component pumped:
6. SySy/ Pyniped
B
Name Vehicle License Number
J&S Development Corp. d/b/a
Stewart's Septic Service, 58 So. Kimball St.,
7. Location ere contents were disposed:
Ste GI bal Env' onmental, L , 20 So. Mill St., Bradford, MA 01835
Same day
Sign ture of aule Date
Same day
Signature of Receiving Facility(or attach facility receipt) Date
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