HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 67 LOST POND LANE 4/16/2025 Commonwealth of Massachusetts TOwn of Nofth Andover
µ- � City/Town of No. Andover MAY 5 2025
System Pumping Record
Form 4 aftd epartment
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,
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:X�r p- w .
`(.. /�
Name
�X SAME
Address(if different from location)
City/Town State _ Zip-Code -
Telephone Number
..w.......
B. Pumping Record
f ..
1. Date of Pumping 2 Quantity Pumped:
Date Ga"Mons
3. Component: ❑ Cesspoal(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:
1 a" ( e All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. System Pumped 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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