HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 110 FOREST STREET 7/6/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of No.Andover JUL 0 6 2022_ System Pumping Record TOWN' ,,:,:NORTH ANDOvER
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,
the he tab,
use only tab
key to move your Address
cursor-do not
use the return Ci /Town
key. �' State Zip Code
2. System Owner:
Name
r&rm
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date' 2. Quantity Pumped: �"�V
G Ions
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes'�s No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6, tem Pumped y:
-0 �)G�tu' K —
Y
Name Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 S .Mill t.,Bradfo d,MA
S nature cuter Date
Signature of Receiving Facility(or attach facility receipt) Date
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