HomeMy WebLinkAboutSeptic Pumping Slip - 163 Candlestick Rd - 11/18/2024 - Septic Pumping Slip - 163 CANDLESTICK ROAD 11/18/2024 = = Commonwealth of Massachusetts
w U� 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.
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A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, // t
use only the tab .
key to move your Address
cursor-do not No Andover MA 01845
use the return _
key. City[Town State Zip Code
2. System Owner:
Name _
e SAME
Address(if different from location)
City/Town State Zip Code
.. _..._.__ _ ........
Telephone Number
. Pumping record
1. Date of Pumping ___. � _"_( - 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) kSeptic 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:
(f All of this estimated
information is non bi- nding, 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
See above
Sig 1.na 11 ture of H 11 au 11 ler date
See above
_
Signature of Receiving Facility(or attach facility receipt) Date
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