HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 153 HAY MEADOW ROAD 4/11/2025 r Commonwealth of Massachusetts TVA/1 North Andover
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City/Town of
w„ stem Pumping Record MAY 202
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K.
Farm 4
DEP has provided this farm for use by local Boards of Health. Other for n$ ijyy'VED0
information must be substantially the same as that provided here, Before using this fo , check wi{h 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,
key to ove your Ad s t use onl the tab
s
cursor-do not MA
use the return _.
key. City/Town State Zip Code
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2. System Owner:
,
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Name /
SAME ff
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
2
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: F-] Cesspool(s) a` eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 2 No If yes, was it cleaned? ❑ Yes n No
5. Observed condition
n component pumped:
" All of this estimated
informatio is non-binding, valid only at the time of pumping. Not responsible beyond the date above,
6. System Pumped By:
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Name Vehicle License Number
J&S Development Corp, d/b/a Stewart's Septic
Service
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7. Location where contents were disposed:
y 20 So. Mill St., Bradford, MA 01835
Stewart Rec �v�ng Facility, ._
d
See above r
Signature of Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc4 11112 System Pumping Record •Page 1 of 1