HomeMy WebLinkAboutNA Animal Hospital - Septic Pumping Slip - 1627 OSGOOD STREET 12/18/2024 Commonwealth of Massachusetts TOM of No over
City/Town of No Andover
7 2
System Pumping JAN 025 Record
Form 4
,C'
DEP has provided this form for use by local Boards of Health. Other forms mpawaug
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 CIVIR 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
use the return
key. Cityffawn State Zip Code
2. System Owner:
J Name __
;kd_d_reii_(if different
No Andover MA -z=P—cow—
City[Town State
"telephone--Number-___________'
B. Pumping Record
2. Quantity Pumped:
1. Date of PumpingGate Gallons
3. Component:
Cesspool(s) Fl_ Septic Tank Tight Tank ❑ Grease Trap
2
[ZOther(describe): P "I
4. Effluent Tee Filter present? W--' Yes [:] No If yes, was it cleaned? [_--�"�i%es ❑ No
5. Observed condition of component pumped-,
6. System P ped By,
't�m
gi r, —
Name Vehicle License Number
Stewart's Se tip58 So Kimball St. , BradfordMA
Company
7. Location where contents were disposed:
20 SoMill St.,Brad-
ure of Hauler Ddte
Signature of Receiving Facility(or attach facility receipt) Date
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