HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 142 BERRY STREET 8/3/2022 Commonwealth of Massachusetts
w W City/Town of No. Andover o 3 �022
System Pumping Record a�� ovEa
Form 4 ���rcN 0E0�
`M JN O p�P Pa
DEP has provided this form for use by local Boards of Health. Other lrms 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, ��nn
use only the tab
key to move your Address
cursor-do not No. Andover MA
use the return City/Town State Zip Code
key.
�1 2. System Owner:
Name —
�un
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
2
1. Date of Pumping pat?—6 " Z 2. Quantity Pumped: —
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes_g�No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of com onenntt pumped-
Observations are driver's opinion based on what he sees at tim of pumping on the date above.
6. S Pumped By:
Name Vehicle License Number
AS Development Corp. d/b/a
Stewart's Septic 58 So. Kimball St., Bradford,MA
7. Location where contents were disposed:
Stewart's Global Environmental, LLC, 20 So. Mill St., Bradford, MA 01835
Same
Signature of Hauler Date
Same _
Signature of Receiving Facility(or attach facility receipt) Date
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