HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 174 INGALLS STREET 12/5/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of No. Andover
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
w 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
1. System Location:
filling out forms Y I I
on the computer, ' /
use only the tab
key to move your Address 01845
cursor-do not No. Andover MA
use the return City/Town State Zip Code
key.
2. System Owner: �
/P C-7 rcA
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record KaD
1. Date of Pumping Date
2. Quantity Pumped: Gallons
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 driver's opinion b e 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
Same
Signature of Hauler Date
Same
Signature of Receiving Facility(or attach facility receipt) Date
System Pumping Record•Page 1 of 1
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