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HomeMy WebLinkAboutSeptic tank - Septic Pumping Slip - 265 HAY MEADOW ROAD 12/5/2022 RECEIVED Commonwealth of Massachusetts W City/Town of No. Andover DEC 0 5 2022 System Pumping Record TOWN OF NORTH ANDOVER Form 4 HEALTH DEPARTMENT �^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, U by �1 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 reaan Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Dare,/�y 2. Quantity Pumped: `c o©(Ions 3. Component: ElCesspool(s) i Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes zNo If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 9 OL,5 d Observations are driver's opinion based 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 � �1 �ornes Same Signature of Hauler Date Same Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1