HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 67 CRICKET LANE 12/8/2024 Commonwealth of Massachusetts Town of North Andover
City/Town of No. Andover
JAN
72025
1 System Pumping Record
f Form 4
DEP has provided this farm for use by local Boards of Health Other farms rn� be &Pgut 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 farm 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 r ,
--- — .. ----..... ...
key to move your Address _
cursor-do not No. Andover MA 01845
use the return ......_.. .
key.
City/Town State Zip Cade
41 Q`W, 2. System Owner:
Name
n 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 [pa No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
All of this estimated
Information Is non-binding, 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
Signature of Hauler Date
_ See above
Signature of Receiving Facility(or attach facility receipt) Date
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