HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 19 CANDLESTICK ROAD 12/5/2022 IL
Commonwealth of Massachusetts
W City/Town of No. Andover qEC 0 5 2022
System Pumping Record
OF NORTH
y1M yvl y`v
Form 4 �"HE HEALTH DEPARTMENTE�
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
key to move your Address
cursor-do not No. Andover MA 01845
use the return ---
key. City/Town State Zip Code
2. System Owner:
Name
S/e o
— ------- --- —------- — -—-- — —
aeon
Address(if different from location)
City,Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping -� I G i - 2. Quantity Pumped: 0
Date G Ions
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:
Observations are iver's opinion based on what he sees at time of pumping on the date above.
6. Syst Pumped By:
D
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 _
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