HomeMy WebLinkAboutSeptic Pumping Slip - 30 Windkist Farm Rd - 10-11-24 - Septic Pumping Slip - 30 WINDKIST FARM ROAD 10/11/2024 Commonwealth of Massachusetts
i
u City/Town of No. Andover
System Pumping Kbcord ry
e�
Form 4
DEP has provided this form for use by local Boards of Health. Other forms mj:tb�eused, but the
information must be su stantiall the same as that provided here. Before using this form, check with your
local Board of Health t�determne the form they use. The System Pumping Record must be submitted to
k the local Board of Heap or other approving authority within 14 days from the pumping date in
accordance with 310 C R 15.351,
i
A. Facility infon ation
fulling out forms en 1. System Location
on the computer, 30 Ks ---use only the tab —C —
Wv
key to move your Address --
r cursor-do not MA 01845
use the return
No.Andover State- -----__— Zip Code--- --
u
key. Cityfrown
2. System Owner j
Name
SAME
Address(if differentfro rrl"16cation) ----� _-- —_._--
Cityfrown State Zip Code
Telephone Number
tm B. Pumping Record
1. Date of Pumping pate - 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) eptie Tank ❑ Tight Tank ❑ Grease Trap
P
❑ Other(describe): ---------- ___..__-_.___..---_..----....___._----__
p 4. Effluent Tee Filter present? ❑ Ye No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of compan nt pumped:
All of this estimated
information is non-binding,valid only at th_time of pum ip ng. Not responsible beyond the date above.
6. System Pumped By:
_---- __ Vehicle license Number
J&.S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewart's Receivin Facility, 20 So. Mill St., Bradford, MA 01835 _
_ _--~ See above
Signature of f Houle �`— -- Date
SAME
Signature of Receiving Facility(or attach facility receipt) _ Date
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