HomeMy WebLinkAboutTight Tank - Septic Pumping Slip - 21 CLARK STREET 5/2/2023 RECEIVED
Commonwealth of Massachusetts MAY 0 22023
u= City/Town of No.Andover TOWN OF NORTH ANDOVER
System Pumping Record HEALTH DEPARTMENT
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:
on the computer,
use only the tab ❑ �(/(� R ��I i
key to move your Address
cursor-do not
use the return City/Town State Zip Code
key.
2. System Owner:
Name
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record Lt CD
1. Date of Pumping Date 2. Quantity Pumped: Galons
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 component pumped:
QCZD
Ij
6. S m Pumped By:
Namcy Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
-- . q d
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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