HomeMy WebLinkAboutSepitc Tank - Septic Pumping Slip - 46 STANTON WAY 6/7/2022 Commonwealth of Massachusetts RECEIVED
w W City/Town of No. Andover
System Pumping Record SUN o'1 Zo22
M Form 4 'OF 1 0B M W R
TOw� L
DEP has provided this form for use by local Boards of Health. Ofl�i��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, Cl / I
use only the tab / 1 t
key to move your Address
cursor-do not No. Andover MA
use the return City/Town State Zip Code
key.
2. System Owner:
�_a W a vr4
Name —
runm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
Z �Z Z 1. Date of Pumping 2 Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) EL/Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ZNo If yes, was it cleaned? ❑ Yes ❑ 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. 13soll
Pumped 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
des e Same
Signature of Hauler Date
Same
Signature of Receiving Facility(or attach facility receipt) Date
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