HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 17 SUGARCANE LANE 12/5/2022 RECEIVED
Commonwealth of Massachusetts
W City/Town of No. Andover
System Pumping Record TOWN Ur NORTH ANDOVER
HEALTH DEPARTMENT
Form 4
w 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: �1
on the computer, 1 �,t 0,,, C"- l G x—
use only the tab
key to move your Address 01845
cursor-do not No. Andover MA
use the return Cityrrown State Zip Code
key.
2. System Owner:
Name
enm
Address(if different from location)
City/Town State Zip Code
i eirpiio ie t4um,6-ar
B. Pumping Record
l ► Iz� lzv , `,
1. Date of Pumping Date 2• Quantity Pumped: 6al Ions
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes\a] No If yes, was it cleaned? ❑ Yes yj No
5. Observed condition f component pumped:
r� �� r � rc,�9c"le i�► ��
Observations are driver's opinion based on what he sees at time of pumping on the date above
6. System Pumped1By: �
t L I��b Vehicle License Number
Name
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
VSiiakture of Hauler Date
Same
Signature of Receiving Facility(or attach facility receipt) Date
System Pumping Record•Page 1 of 1
t5form4.doc•11/12
