HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 796 WINTER STREET 9/6/2024 Commonwealth of Massachusetts
City/Town of No. Andover
IR -_ System Pumping Record
;tea Form 4
J'
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 CM 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 01985
use the return ------ ---. — -- - --- — - --- - — -- -
key. City/Town State Zip Code
lf�� 2. System Owner:
V1— i
Name
SAME
Address(if different from location)
CitylTown State Zip Code
Telephone Number
B. Pumping Record
7 Z O
1. Date of Pumping Date ZZ 2. Quantity Pumped: Galldns
3. Component: ❑ Cesspool(s) [*—Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): — -----
4. Effluent Tee Filter present? ❑ Yes [SNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observe conditi n of component pumped:
All of this estimated
information is non-binding, valid only at the time of puffing. Not responsible beyond the date above.
6. System ed Bf :
7veo
Name Vehicle License Number
J&S Development Cor d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewart's Receiving Facility, 20 So. Will St., Bradford, MA 01835
See above
Signature of Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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