HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 38 GILMAN LANE 12/5/2022 kbCEivi=if
Commonwealth of Massachusetts DEC 0 5 2022
rp City/Town of No. Andover
System Pumping Record f9W OFNORTHA DDEPART TEH
Form 4 N
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, A 41
use only the tab
key to move your Address
cursor-do not No. Andover MA 01845
use the return Cityrrown State Zip Code
key.
2. System Own r:
Name
ream
Address(if different from location)
City/Town State Zip Code
Telephone Nur:rber
B. Pumping Record
2 2-
1. Date of Pumping 2.Date Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) eptic 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 com on t pumped:
Obsery ons re driver's opinion based on what he sees at time of pumping on the date above.
6. Syste um ed By: J
Name Vehicle Li nse Number
J&S Development Corp. d/b/a
Stewart's Septic 58 So Kimball St. Bradford,MA
7. Location where contents were disposed:
Stewa a nvironmental, So. Mill St., Bradford, MA 01835
Same
Signa r Date
Same
Signature of Receiving Facility(or attach facility receipt) Date
System Pumping Record•Page 1 of 1
t5form4.doc• 11/12