HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 356 RALEIGH TAVERN LANE 4/11/2025 Commonwealth of Massachusetts ",n Of i'Yo ndover
City/Town of No. Andover
w=� System Pumping Record MAC 5 2025
q
Form 4
DEP has provided this form for use by local Boards of Health. Other dorms gM11ut 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,
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: ❑ .y. ,
Name
SAME
Address(if different from location)
_..
City/Town State Zip Code
Telephone Number
B. Pumping Record
1 Da� � '"..� � ,,.. d"❑_ Gallons�
. Date of Pumping 2. Quantity Pumped:
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): _ `
4. Effluent Tee Filter present? ❑ Yes - o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed co dition of c mponent pumped:
C9 All of this estimated
information is non-bindirdvalid only at the time of pumping. Not responsible beyond the date above.
6. 8y mped y. a
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Steles rt'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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