HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 200 BRADFORD STREET 12/5/2022 Commonwealth of Massachusetts RECEIVED
City/Town of No. Andover DEC 0 5 2022
System Pumping Record
V
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,
use only the tab Z-oD O7�it�-nk s�—
key to move your Address
cursor-do not No. Andover
use the return MA 01845
key. City/Town State Zip Code
2. System Owner:
_ 1OS cc 4
Name
Address(if different from location)
Citylrown State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date ZZ 2. Quantity Pumped:
Gallorrs
3. Component: ❑ Cesspool(s) O/Septic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑ Yes LI No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:I
Observations are driver's opinion bake bakeA on what he sees at time of pumpinq on the date above.
6. System Pumped 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
ure auler Date
Same
Signature of Receiving Facility(or attach facility receipt) Date
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