HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 GRAY STREET 6/13/2025 .� Commonwealth of Massachusetts Town of jVO"tn AndoVer
City/Town of No. Andover JUL
4° System Pumping Record 2025
a Form 4 f, alt
DEP has provided this form for use by local Boards of Health. Other forms may be used bauftent
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 f
cursor-do not No. Andover MA 01845
use the return
key. City/Town State Zip Code
2, System Owner:
Name
SAME
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record 6 1,
1. Date of Pumping pate 2. Quantity Pumped: /,51L _)
Gallons r
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): - - -- - -_
4. Effluent Tee Filter present? ❑ Yes..K No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
All of this estimated
information is non-binding, o only at the time of pumping. Not responsible beyond the date above.
6. Sys mped 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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