HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 170 OLYMPIC LANE 2/25/2025 Commonwealth of Massachusetts
w City/Town of No. Andover 2025
System Pumping Record
/w Farm 4 p
)epartrnent
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 farm, 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 farms 1. System Location:
on the computer, p /
use only the tab (
key to move your Address
cursor-do not No. Andover MA 01845
use the return key. City/Yawn State Zip Cade
VQ 2. System Owner:
Name
SAME
Address(if different from location)
-- __ __ --
City/Town State Zip Code
Telephone Number
.__,..._.._..... �_._._.._.._..._........ ...... ..__ __.-__.__.__,_... _.. _.._ ......
B. Pumping Record
- x - 16,00
1. Date of Pumping Date 2. Quantity Pumped: Gallons 11
1Component: ❑ 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 pumped:
. If All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
.
6. System P mped By-
Na e - 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
Sign ture of Houle Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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