HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1560 SALEM STREET 8/3/2022 RECENED
Commonwealth of Massachusetts AEG 3 2022
u W City/Town of No. Andover ANppVER
System Pumping Record TowNofNO51"EpA rmvv
r` Form 4
HEALTH
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, /'l 6 0 SCi �C/Vl
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
2. System Owner:
(,alu
Name -_
lean
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) 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 component pumped:
Observations are driver's opinion b ed oo�nn w%hat he sees at time of pumping on the date above.
6. System Pumped By:
Name Vehicle License Number
J&S Development Corp. d/b/a
Stewart's Septic 58 So. Kimball St., Bradford,MA
7. Location where contents were disposed:
Stewart's GjQbal Enviro ,: LC, 20 So. Mill St., Bradford, MA 01835
Same
ature of Ha Date
Same
Signature of Receiving Facility(or attach facility receipt) Date
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