HomeMy WebLinkAboutSeptic Pumping Slip - 136 Stonecleave Rd - 9.18.2024 - Septic Pumping Slip - 136 STONECLEAVE ROAD 9/18/2024 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,
r)
use only the tab _ —__........_............_. _ .. ___- ._._. , ' "I . Q GL �:..--
key to move your Address
cursor-do not No. Andover MA 01985
use the return _ _ _._ _ .
key.
City(Town State Zip Code
2. System Owner:
, ry
Name
SAME
Address(if different from location)
City-/Town State Zip Code
Telephone Number
B. Pumping Record
1. Cate 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 ❑No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
C (7
All of this estimated
information is non-binding, valid only„at the time of pumping. 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:
Stewart's Receiving Facility, 20 So. Mill St., Bradford, MA 01835
" - _..__ C C See above
...---.................... __.. .... ...... ....
Signature of Hauler Date
See above
_ _..... ..........._... -._...
Signature of Receiving Facility(or attach facility receipt) Date
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