HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 386 GREAT POND ROAD 1/31/2025 ram, Commonwealth of Massachusetts
N p City/Town of No. Andover
w° System Pumping Record
,n m-
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
filling out forms 1. System Location:
on the computer, C
use only the tab _114'
key to move your Address
--
cursor-do not No. Andover MA 01845
use the return key. City/Town State Zip Code 2. System Owner: own Of 0 h Andover
Name
SAME FEB ^ Oz
Address(if different from location)
City/Town State --
e
Telephone Number
B. Pumping Record
w
1. Date of Pumping Date 2. Quantity Pumped: II
Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
e):Other (describ _ ~
4, Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5, Observed condition of component pump d:
f` l « PA i, All of this estimated
information is non-binding, ali only at the tim6 o pumpin . Not responsible beyond the date above.
6. System Pmd B4-yl
- --
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
..
atu Hauler Date
See above
_ -_-___. -- _-
Signature of Receiving Facility(or attach facility receipt) Date
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