HomeMy WebLinkAboutSeptic Pumping Slip - 137 Hay Meadow - 11/15/2024 - Septic Pumping Slip - 137 HAY MEADOW ROAD 11/15/2024 Commonwealth of Massachusetts
City/Town of No. Andover
System Pumping Record
,.: :.. Farm 4
DEP has provided this farm 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, 17
use only the tab _ ._#_� - - t�)
key to move your Address
cursor-do not No. Andover MA 01845
use the return -__ -- _
key. City/Town State Zip Code
�rob 2. System Owner:
�t
Name
awn 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) eptic 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-bin ng valid only at the time of pumping. Not responsible beyond the date above.
6. $y Pumped By:
Name.,.
Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
e wart's Receiving Facility, 20 So. Mill St., Bradford, MA 01835
See above
w:...- -
Signa#ure of Hauler �° Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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