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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 10 HAWKINS LANE 10/3/2022 �L\ Commonwealth of Massachusetts ijece1\02 w City/Town of No. Andover 21 } W° System Pumping Record pCj p 320 Form 4 o�NDtNP MEND 1N os?N DEP has provided this form for use by local Boards of Health. Other forms may bk Culsed, 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, to 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: re6 Name -- -- ream Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record r 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) t6eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): - 4. Effluent Tee Filter presentf-[�Yes ❑ No If yes, was it cleaned? Yes ❑ No 5. ObseZ' condition n ,compon ©0ed: Observations are driivvler's opinion based on what he sees at time of pumping on the date above. 6. Syste u Zdl By:L '17 — 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' 0 So. Mill St., Bradford, MA 01835 Same Date _ ------- - Same _ Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11112 System Pumping Record•Page 1 of 1