HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 62 BANNAN DRIVE 12/5/2022 Commonwealth of Massachusetts RECEIVED
City/Town of
�m System Pumping Record
Form 4
I OWN OF NORTH ANDOVER
7- ETA
"EDIT
DEP has provided this form for use by local Boards of Health. y 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, &/Vuse only the tab l j j'IU
key to move your Address
cursor-do not N 0 Jcr MA
use the return City/Town State Zip Code
key.
:a
2. System Owner:
Name
ienm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
3. Component: ❑ Cesspool(s) �eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -- -- ----- - - -
4. Effluent Tee Filter present? ❑ Yes S No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped: nl
6. System ump By:
Name ` Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill ., Brad , M
n re �Hfim Da e
Same day
Signature of Receiving Facility(or attach facility receipt) Date
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