HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1794 SALEM STREET 10/3/2022 F1ECEIVEC'
�L\ Commonwealth of Massachusetts
City/Town of No. Andover 0 32p22
At4aOVE�
System Pumping Record �DWt40 ND pA TMEN�
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, (� (�/ S�
use only the tab
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
Name
raun
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) Lam'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 e on what he sees at time of pumping on the date above.
6. System 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
gn Hauler Date
Same
Signature of Receiving Facility(or attach facility receipt) Date
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