HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 221 FARNUM STREET 12/5/2022 Commonwealth of Massachusetts RECEIVED
City/Town of No. Andover
W° System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
M DEALT H P.EPARTMENT
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 I
key to move your Address
cursor-do not No. Andover MA 01845
use the return —
key. City/Town State Zip Code
2. System Owner:
6am f
Name —--- —
ratrm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
60 1. Date of Pumping C t- (-7- ZZ 2. Quantity Pumped: o
Date 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 umped:
he jqv. .5(D hAs
Observations are driver's opinion based hat he sees at time of pumping on the date above.
6. System Pumped By:
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 _
i e o aule Date
Same
Signature of Receiving Facility(or attach facility receipt) Date
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