HomeMy WebLinkAboutSeptic Pumping Slip - 90 Bradford St - 11/15/2024 - Septic Pumping Slip - 90 BRADFORD STREET 11/15/2024 q Commonwealth of Massachusetts
City/Town of No. Andover
4_ ❑ System Pumping Record
Form 4
DEP has provided this farm for use by local Boards of Health. Other farms 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 999
key to move your Address
cursor-do not No. Andover MA 01845
use the return
key. City/Town State Zip Code
w 2. System Owner:
, r�
Name
�n SAME
_.. .. .w.
Address(if different from location)
........
City/Town State Zip Code
Telephone Number
B. pumping Record
Date Gallon
2. Quantity Pumped:
1, Date of Pumping
s
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_o4 at the time of pumping. Not responsible beyond the date above.
6. Syste�rl..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 df Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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