HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 196 CARLTON LANE 11/3/2022 Commonwealth of Massachusetts RECEIVED
W City/Town of No. Andover Nov o 3 2022
W° System Pumping Record
Form 4 TQWN OF NORTH HEALTH DEPARTMENT
EB
M
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, t! -
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:
r� .
r0 S S
Name —
Isom
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record _
1. Date of Pumping — '� Z2. 2. Quantity Pumped: 50 0
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 2 No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
Observations are driver's opinion based n hat he sees at time of pumping on the date above.
6. System P mped By:
'0 Iq S
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 GloU4 Environmental, LLC, 20 So. Mill St., Bradford, MA 01835
_ Same
gn of u Date
Same
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1