HomeMy WebLinkAboutSeptic Pumping Slip - 1288 Salem St - 10-18-24 - Septic Pumping Slip - 1288 SALEM STREET 10/18/2024 Commonwealth of Massachusetts
- � City/Town of No. Andover
,System Pumping Record
Farm 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 lumping 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: 4
computer,on the
use only
move tab
Y your Address ,
cursor-do not No. Andover MA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
Name
Btrsn 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 if cleaned? es ❑ No
5. Observed condition f component pumped:
G 0 C.d All of this estimated
information is non-binding, valid only at_the time of pumpinc�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
See above
-- _ --....... .. ---_
Signature of Hauler Date
SAME
Signature of Receiving Facility(or attach facility receipt) Date
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