HomeMy WebLinkAboutSeptic Pumping Slip - 351 Willow St 9.6.2024 - Septic Pumping Slip - 351 WILLOW STREET 9/6/2024 (3) Commonwealth of Massachusetts
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:
on the computer, ") 1 6
use only the tab _ _._-___ __---.— �� I
key to move your Address
cursor-do not No. Andover MA 01845
use the return
key. City/Town State Zip Code
r 2. System Owner:
_._...... .... _...
Name
seen SAME
_ ___ -..._.__.. _.__. ..._ _._ ., _ .....
Address(if different from location)
_..-....... -- _.. --.__. .....
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping - 2. Quantity Pumped: - —
Date Gallons
3. Component: ❑ Cesspool(s) ❑ 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:
» All of this estimated
Information is non-binding, valid only at the time of pum ing. Not responsible beyond the date above.
6. System Pumped By:
.
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
,,ivin Facll� 20 So. Mill St. Bradford MA 01835 Stewart's R _.
. See above
ture of Hauler Date
�: _........ ... ....... . .w__._ _. SAME
Signature of Receiving Facility(or attach facility receipt) Date _...
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