HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 240 FARNUM STREET 11/3/2022 Commonwealth of Massachusetts
City/Town of No. Andover Ce'vEr
a System Pumping Record
Form 4 3 R
PNppVE
C
DEP has provided this form for use by local Boards of Health. Other form-jlNay !�{. "g, �®fit Pte
information must be substantially the same as that provided here. Before us�i orm, 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
key. City/Town State Zip Code
2. System Owner:
CC Ja
- - -- - - - -
Name
rerun
Address(if different from location)
City/Town State Zip Code
_ Telephone Number
B. Pumping Record /
1. Date of Pumping �3 ZZ 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) J� 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:
t�u_yvt0 For �X Id. Y�O�cz�p ✓
Observations are driv is opirion based on what he sees at time of pumping on the date above.
6. System PumpedBy:
✓U� _
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 jp1obal Envi ental, LC, 20 So. Mill St., Bradford, MA 01835
x/4- Same
S' ature of auler Date
Same
Signature of Receiving Facility(or attach facility receipt) Date
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