HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 102 LACY STREET 12/5/2022 �,,�
Commonwealth of Massachusetts RECEIVED
City/Town of No. Andover
System Pumping Record N Cr NORTH ANDOVER
Form 4 TOW
w„ 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, M D q C
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:
ras
Name
ream
Address(if different from location)
City/Town State Zip Code
Telephone Numbar
B. Pumping Record
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? El Yes ] No If yes, was it cleaned? ❑ Yes No
5. Observed condition of component pumped:
Observations are driver's opinion based on what he sees at time of pumping on the date above.
6. SMumped 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
( I Same
Signature of Hauler Date
Same
Signature of Receiving Facility(or attach facility receipt) Date
System Pumping Record•Page 1 of 1
t5form4.doc•11112