HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 240 RALEIGH TAVERN LANE 1/5/2023 RECEIVED
,C\ Commonwealth of Massachusetts JAN 0 5 2023
u City/Town of TOWN OF NORTH ANDOVEF
System Pumping Record HEALTHUEPARTMENT
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:
uon the se only
computer, �/�,/1�
use only the tab i/ /
key to move your Address
cursor-do not MA
use the return City/Town State Zip Code
key.
2. System Owner:
Vj-�Z�
Name
reran
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date . Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ff No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition, ppf component pum ed:
Observations are drive es opinion based on what he sees at time of pumping on the date above.
6. System Pum d By:
i'j, V /�
Name Vehicle Lic se Number
J&S Develo ent 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
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