HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 30 STANTON WAY 12/5/2022 Commonwealth of Massachusetts RECEIVED
W City/Town of No. Andover
i
System Pumping Record DEC 0 5 2022
M Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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, 30
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:
r�
Name
rerun
Address(if different from location) — —
CitylTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Datei y 2 Quantity Pumped: 0
Ilons
3. Component: ❑ Cesspool(s) 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:
-txce,c�,rvp
Observations are driver's opinion based on what he sees at time of pumping on the date above.
6. Mumped By:
C0'rl_
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
,/;�Q Same
Signature of Hauler Date
Same
Signature of Receiving Facility(or attach facility receipt) Date
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