HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 2211 TURNPIKE STREET 5/1/2025 Commonwealth of Massachusetts rbrfi;" of a h
City/Town of No. Andover ,�dQVer
System Pumping Record JOIN
4 ❑ Form 4 Z�ZS
DEP has provided this form for use by local Boards of Health. Other forms m4 dd put the
information must be substantially the same as that provided here. Before using this#or , Ihy�lth 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 _ ` ,' /f Cf�° '
key to move your Address
cursor-do not No. Andover MA 01845
use the return ----— --- -
key. City/Town State Zip Code
Z System Owner:
Name
SAME
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping -- --- --- ~Quantity Pumped:
Date Gallons
3. Component: ❑ 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 co ponent pumped:
All of this estimated
information is non binding, valid only at the time of pumping_ Not responsible beyond the date above.
6. System P ped By:
ry �
r c
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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