HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 369 SALEM STREET 5/2/2023 Commonwealth of Massachusetts RECEIVED
w City/Town of _ I",AY 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: _ -51
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on the computer, of /� `I
use only the tab f
key to move your Address ((��
cursor-do not ���r� MA V 1(sq_5
use the return City/Town State Zip Code
key.
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping D _ 2. Quantity Pumped: 000
-
e Gallons
3. Component: ❑ Cesspool(s) ZSeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 21"'No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pump d By:
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill qLBfadf0Td, MA
q- 1Ll- o3
a of Haul Date
Same day
Signature of Receiving Facility(or attach facility receipt) Date
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