HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 65 SPRING HILL ROAD 9/6/2022 RECEIVED
Commonwealth of Massachusetts
_ City/Town of No. Andover SEp o 6 2022
System Pumping Record TOWN OF NORTH ANDOVER
r Form 4 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 CM 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, //
use only the tab 65- S'g/7
key to move your Address —�
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
01-� 2. System Owner:
m
Name
rmun
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
n
1. Date of Pumping , 2 Z 2. Quantity Pumped: OC�
Date Gallons
3. Component: ❑ Cesspool(s) 11?rSeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes CT No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
jN ltt 00 I
Observations are driver's opinion based on what he seeSlef 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 GlobaLUnvironmental, LLC, 20 So. Mill St., Bradford, MA 01835
-- Same
ture of Hauler Date
Same
Signature of Receiving Facility(or attach facility receipt) Date
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