HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 115 LACONIA CIRCLE 6/4/2025 Commonwealth of Massachusetts gown of North Andover
City/Town of pc> .
'system Pumping Record JUN 4 025
Form 4
M; h
DEP has provided this form for use by local Boards of Health. Other forms may be uspecp, PRAMent
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 1 1_ q 4-11,C cy I `�,-.. C V
key to move your Address
cursor-do not MA
use the return -
key. City/Town State Zip Code
r�
2. System Owner:
� Name
almn SAME
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping e 2. Quantity Pumped: Irons
3. Component: ❑ Cesspool(s) 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 co dition ofomponent pumped:
&-"— All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. Syste roped By: ,
M,.
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. Mili 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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