HomeMy WebLinkAboutSeptic Tank / Tight Tank - Septic Pumping Slip - 21 CLARK STREET 9/6/2024 Commonwealth of Massachusetts
W City/Town of No. Andover
System Pumping Record
Form 4
M
Q
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, y� ��
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
, .n SAME ---- — --- ---
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
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? [Ell Yes o 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 pumpog. Not responsible beyond the date above.
6. System Pumped By:
Lc4 �_ ---
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewart's Receiving Facility, 20 So. Mill St., Bradford, MA 01835
__. / p�,, See above
Signature of Ha e�r Date
SAME
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
ft City/Town of No. Andover
System Pumping Record
Form 4
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: 1
on the computer, vp
use only the tab
key to move your Address
cursor-do not No. Andover MA 01985 _
use the return City/Town State Zip Code
key.
r�
2. System Owner:
_ D w�-r �I: ✓G� I�
Name
SAME _
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dat 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank Ti ht Tank ❑ Grease Trap
❑ Other(describe): — - ��,,, — ----- -
4. Effluent Tee Filter present? ❑ Yes L9__No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of omponent pumped:
(cm�l6(4 All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. Syst ump d By:
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewart's Receiving Facility, 20 So. Mill St., Bradford, MA 01835
See above
Signature of Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1