HomeMy WebLinkAbout- Septic Pumping Slip - 1551 OSGOOD STREET 2/6/2023 RECEIVED
Commonwealth of Massachusetts
_ W City/Town of No. Andover
System Pumping Record rOwN OF NOR-rH ANDOVER
Form 4 HEALTH DEPARTMENT
M
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, D
use only the tab ._.
key to move your Address
cursor-do not No. Andover MA ` 01845
use the return CitylTown State Zip Code
key.
2. System Owner:
VS" lGawale GaQ�
Name
men
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
I
1. Date of Pumping Date 2. Quantity Pumped: G fl Js��
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -
4. Effluent Tee Filter present? ❑ Yes 2 No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
Observations are driver'sq�pinion based on what he sees at time of pumping on the date above.
6. System Pumped By:
Name — Vehicle License Number
AS D vOlopment Corp. d/b/a
Stewarl;5 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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