HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 INNIS STREET 8/3/2022 ilex D
ICN Commonwealth of Massachusetts
City/Town of No. Andover a�6 0 3'loti2
System Pumping Record oEa
Form 4 HN(-WSN0�;?k5l
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 key. City/Town State Zip Code
�I1 2. System Owner:
r�
Name
nAm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping - �� Z� 2. Quantity Pumped: ns •vim ----
Datee Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Ye9ofo
5. Observed condition of component pumped:
Observations are driver's opinion based on what he sees at time of pumping on the date above.
6. Systmped By:
e u
fib
Name Vehicle Li se Number
J&S Development Corp. d/b/a
Stewart's Septic 58 So. Kimball St., Bradford,MA
7. Location ontents were d:
ewart's Global Environmental, LLC, 20 S ill St., Bradford, MA 01835
Same
Signa re of Hauler Date
Same
Signature of Receiving Facility(or attach facility receipt) Date
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