HomeMy WebLinkAboutTight Tank - Septic Pumping Slip - 21 CLARK STREET 7/11/2025 Commonwealth of Massachusetts gown � �
z - -- City/Town of No. Andover Andover
System Pumping Record
Farm 4 AUG 1 1 2025
DEP has provided this form for use by local Boards of Health. Other fo m b s na"ed, but the
information must be substantially the same as that provided here. Befo your
local Board of Health to determine the form they use. The System Pumping Recordt be submited 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
cursor-do not No, Andover MA 01845
use the return key. City/Town State Zip Code
2. System Owner: "
rah
Name
SAME
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dat I e
f_( 2. Quantity Pumped: G µ�
Ilons
3. Component: ❑ Cesspool(s) eptic 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 componnt pumped:
,-I All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. System Pumpe 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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