HomeMy WebLinkAboutSeptic Pumping Slip - 174 Gray St - 11/4/2024 - Septic Pumping Slip - 174 GRAY STREET 11/4/2024 Commonwealth of Massachusetts
a g CityfTown 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.
A. Facility Information
Important:When 666
filling out forms 1. System Location:
on the computer,
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
'f�Qb 2. System Owner:
---
Name
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 it cleaned? ❑ Yes ❑ No
5. Observed condition of component pu pe❑2
'�%"�6 All of this estimated
information is non binding, valid only at the time of pumping, Not responsible beyond the date above.
6. Syste Pumped By:
Name C Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewart's, R F 2 So. i t., Br d, MA 01835
..
See above
_. --. --
ature Date
See above
— -- -- __ -- --
Signature of Receiving Facility(or attach facility receipt) Date
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