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HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 71 CANDLESTICK ROAD 7/6/2022 Commonwealth of Massachusetts RECEIVED City/Town of No.Andover JUL 0 6 2022 Il -_ System Pumping Record j Form 4 TOWN CW ����;�'TH ANDOVER 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 key to move your Address cursor-do not use the return City/Town State Zip Code key. 2. System Owner: r� file Name ream Address(if different from location) No.Andover MA City/Town State Zip Code Telephone Number B. Pumping Record ` ls4z? 1. Date of Pumping Date r 2• Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) V Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes No 5. Observed condition of comRon�glta�pel: 6. System ©frtped Bye Ar — Name Vehicle L ense Number Stewart's Septic 58 So Kimball St. , Bradford,MA Company 7. Location where contents were disposed: 20 So. t.,Bradford,MA Si o Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1