HomeMy WebLinkAboutSeptic Pumping Slip - 84 Academy Ln - 11/25/2024 - Septic Pumping Slip - 84 ACADEMY ROAD 11/25/2024 Commonwealth of Massachusetts
.: City/Town of No. Andover
_ k Pumping Record
Systemp �
Form 4
DP 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,
_ __--- .__..._...._...._..............._..._..........__-_--
Ai. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, // 1
use only the tab
key to move your Address
cursor-do not No. Andover MA 01845
use the return -- _ _ _
key. City/Town State Zip Code
2. System Owner:
Name
SAME
...... .......... _
Address(if different from location)
. .
City/Town State Zip Code
_ -....._ -----------
Telephone Number
_ ----.....................----------._
B. Pumping Record
60
1. Date of Pumping _--------------1-1111 2. Quantity Pumped: �
Date Gallons
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:
All of this estimated
information is non-binding, valid only at the time of pumping:_Not responsible beyond the date above.
6. :,ys,_m Pum ed B : Vehicle License Number
AS Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewark s R rng Fa ct,v, 20 illt., ford, .MA 01835
"- See above
'dig a ure of Ha Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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