HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 356 REA STREET 5/2/2023 RECEIVED
IL
Commonwealth of Massachusetts
u W City/Town of No. Andover MAY 0 22023
System Pumping Record TOWN OF NORTH 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,
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. p
2. System Owner:
reb
Name ---- —
r�m
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping '(Z� — 2. Quantity Pumped: -
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -
4. Effluent Tee Filter present? ❑ YesxNo If yes, was it cleaned? ❑ Yes n No
5. Observed condition of component pumped:
Observations are driver's opinion based on what he sees at time of pumping on the date above.
6. SyP� ped By:
Name Vehicle License Number
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 _
Signature of Hauler Date
Same
Signature of Receiving Facility(or attach facility receipt) Date
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