HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 351 WILLOW STREET 12/9/2024 W
Commonwealth of Massachusetts pa�r` tn�a"OVe1"
City/Town of No. Andover
System Pumping Record JAN 7 225
p Form 4
fl
DEP has provided this form for use by local Boards of Health. Oth I t,i a
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 t'.j
key to move your Address
cursor-do not No, Andover MA 01845
use the return - -
key. City/Town State Zip Code
r 2, System Owner:
y L
Name
fl SAME
Address(if different from location)
- --...... .........
City/Town State Zip Code
Telephone Number
B. Pumping Record
C7ate
1. Date of Pumping 2. Quantity Pumped: �
n 11 s
3. Component: F-1 Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ... _ .
4. Effluent Tee Filter present? ❑ Yes Ja..No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed con�jtion of component pumped:
" ` .._. All of this estimated
information is non binding, valid only at the time-of pumping. Not responsible beyond the date above.
& System Pumped By
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
St Bradford, MA 01835
- � ,r Ing Facility, 20 �
tewa s Receiving oI
..' - ' ....... .. __. See above
Signature of Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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