HomeMy WebLinkAboutTight Tank - Septic Pumping Slip - 21 CLARK STREET 3/12/2025 Commonwealth of MassachusettsTO
ar _ = p City/Town of No. Andover v ,r
4 stem Pumping Record
Farm 4 R - 025
DEP has provided this form for use by local Boards of Health. Other far e used, but the
information must be substantially the same as that provided here. Before � i your
local Board of Health to determine the form they use. The System Pumping Recorfm4=td 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
........------------.. _. ._. — - —.._. _. ......._...-_. . .... .
key to move your Address
cursor-do not No. Andover MA 01845
use the return --_. _ - _ _
key. City/Town State Zip Code
2. System Owner:
Name
PBPtp71 SAME
Address(if different from location)
CitylTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping �. 2. Quantity Pumped: - _.....
Date Gallons
3. Component: F1 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:
All of this estimated
information is non-binding, vali _ y at the time of pumping. Not responsible beyond the date above.
6. System Pun) 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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