HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 361 CHICKERING ROAD 12/5/2022 �ECEtVED
Commonwealth of Massachusetts ; 052022
Y City/Town of No. Andover TC T
System Pumping Record-
Form 4
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, �3 / 01/ 1 4e r,
use only the tab
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
iUbc
Name
ream
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record I /
✓ 7�� Quanti Pumped: /�O�
1. Date of Pumping Date Gail s
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes k-No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of compo ent pumped:
06
Observations ar river's opinion based on what he sees at time of pumping on the date above.
6. System pe By:
conr—
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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