HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 2189 SALEM STREET 6/6/2023 Commonwealth of Massachusetts
City/Town of No. Andover
System Pumping Record,®
Form 4
,LAM
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:
on the computer, �_ /
use only the tab ? / G` 7 J C'X/e
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System.Owner:
--01
Name
ream
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record 15 0
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) [)Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes j No If yes, was it cleaned? ❑ Yes WNo
5. Observed condition of m�onent pumped:
Observati ns are driver's opinion based on what he sees at time of pumping on the date above.
6. Syste Pumped-Sy: ;
ILC
Name al^✓ L 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 Globa ELivironmental, LLC, 20 So. Mill St., Bradford, MA 01835
Same
na Date
Same
Signature of Receiving Facility(or attach facility receipt) Date
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