HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 514 WINTER STREET 12/5/2022 Commonwealth of Massachusetts RECEIVED
W City/Town of No. Andover
System Pumping Record
Form 4 TOWN OF NOR`I ANDOVE`'
HEALTH DEPARTMEW,
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
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owner: q
k
Name
�n
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
It -Z3 —zZ ) S��
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 compo ent pumped-- y% ✓
(2-, r7, I W
-I V,
Observations ver's opinion based on what he sees at ti of pumping on the date above.
6. Syste Pumped By:
Nam& Vehicle ense Number
J&S Development Corp. d/b/a
Stewart's Septic 58 So. Kimball St., Bradford,MA
7. Location where contents were disposed:
Stewa ' nvl LC, 20 So. Mill St., Bradford, MA 01835
Same
Sign ��auler Date
Same
Signature of Receiving Facility(or attach facility receipt) Date
System Pumping Record•Page 1 of 1
t5form4.doc• 11/12