HomeMy WebLinkAboutSeptic Tank - Tote - Septic Pumping Slip - 21 CLARK STREET 12/5/2022 Commonwealth of Massachusetts
W City/Town of No. Andover
W° System Pumping Record �tiotiti
Form 4 No���
o0\01
F
DEP has provided this form for use by local Boards of Health. Other forms may II� �
information must be substantially the same as that provided here. Before using t�i�s�a 'f 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, /
use only the tab
key to move your Address
cursor-do not No. Andover
use the return MA 01845
key. City/Town State
Zip Code
2. System Owner:
Name 61
��� IZLC l�V lt/�
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. �Co�mponent: ❑ Cesspool(s) Septic Tank El Tight Tank ❑ Grease Trap
LJ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
'qo"�d
Observations are driver's opinion ba—s-eQofi what he sees at time of pumping on the date above
6. System P red 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 Global Environmental, LLC, 20 So. Mill St., Bradford, MA 01835
Same
ig re of Hau r Date
----------------------
Same
Signature of Receiving Facility(or attach facility receipt) Date
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