HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 445 FOREST STREET 6/7/2022 RECEIVED
Commonwealth of Massachusetts
W City/Town of No. Andover JUN 0 7 2022
System Pumping Record TONW'I OF NORTH ANDOVER
Form 4 H_aLTH DEPARTMENT
µM
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, I G f 1 �o Y-es C
use only the tab `mil `�i J J
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
V/A` fi�eVJ,FCh
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping - 2. Quantity Pumped: ��G
Date Gallons
3. Component: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? �es ❑ No If yes, was it cleaned? 10/yes ❑ No
5. Observed condition of component pumped:
IQ,�:,�
6. System Pumped By:
/1 tson
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
0 j Same day
Signature of Hauler Date
Same day
Signature of Receiving Facility(or attach facility receipt) Date
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