HomeMy WebLinkAboutTight Tank - Septic Pumping Slip - 21 CLARK STREET 6/4/2025 �w
dOV �Commonwealth of Massachusetts
City/Town of No. Andover ° '25
System Pumping Record
Y p ��.
Form 4
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 CM 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/lawn State Zip Code
r�
2. System Owner:
Name -
t
SAME
Address(if different from location)
City/Town State Zip Code
i n
Telephone Number
B. Pump
ing g Record
1. Date of Pumping date 2. Quantity Pumped; Gallons
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 0ndition f component pumped:
All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. Sys t ump d 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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