HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 651 TURNPIKE STREET 10/3/2022 _
Commonwealth of Massachusetts �� t�t�
W City/Town of No.Andover 32022
System Pumping Record ��� A;�oov�►-
Form 4 rOWN aF NpEPA SMENT
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, �/ 'Tarn pIKG �,
use only the tab
key to move your Address
cursor-do not
use the return Cityrrown State Zip Code
key.
2. System Owner:
Name
ream
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
7�--
1. Date of Pumping Date( 2• Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
Other (describe): �eut7 1p C 9 c ry•�c_�--
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
CAS /�
6. System Pumped
Nam Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
MSigntu're
IISt"BradfordMA
L
f Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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