HomeMy WebLinkAboutSeptic Pumping Slip - 45 Boston St 10-3-2024 - Septic Pumping Slip - 45 BOSTON STREET 10/3/2024 G Commonwealth of Massachusetts
µ, City/Town of No. Andover
System Pumping Record
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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,
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
VQ 2. System Owner:
Name
lj;zm SAM E
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping _._.__. 2. Quantity Pumped:
[late 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:
�, )J All of this estimated
Information is non binding,-valid only at the 'm of pumping. Not responsible beyond the date above.
6. Syste Pu ped By:
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewarts Viceiving Facility, 20 So. Mill St., Bradford, MA 01835
�°`f Se Hauler Date above
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e
See above
Signature of Receiving Facility(or attach facility receipt) Date
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