HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 120 CANDLESTICK ROAD 6/4/2025 Commonwealth of Massachusetts h "'o"r
City/Town of No. Andover iuN 20
25
z - System Pumping Record
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Form 4
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DEP has provided this form for use by local Boards of Health. Other forms may be usUe9.,7IQfte
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 (`2id
key to move your Address
cursor-do not No. Andover MA 01845
use the return _
key.
City/Town State Zip Code
Q
2, System Owner:
I
_-- f (`P P Q P✓1�7 d 9
.Name
SAME
Address(if different from location)
City/Town State Zip Code
Telephone Number
Et.�Pumlping Record __._._....__......_..__._ ._... ..._. _ -______
1. Date of Pumping Date Gall 2. Quantity Pumped: o
ons
3. Component: ❑ Cesspool(s) E Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? F Yes ❑ No
5. Observed condition of component pumped:
❑ > All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. Sy em P umpe y:
Vehicle License Number
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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