HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1044 SALEM STREET 7/23/2025 Commonwealth of Massachusetts TOwn of NoM AndOver
City/Town of L- cuQ-c
System Pumping Record AUG 112025
Form 4
Healt
DEP has provided this form for use by local Boards of Health. Other forms N99M&*r4Mt
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 b-X,\eM
key to move your Address
cursor-do not MA
use the return
key. City/Town State Zip Code
VQ 2. System Owner:
Name
Address(if different from location)
City/Town -State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: joon
Date/ Gallons
3. Component: 7 Cesspool(s) Septic Tank 7 Tight Tank 7 Grease Trap
7 Other(describe):
4. Effluent Tee Filter present? 7 Yes � No If yes, was it cleaned? 7 Yes 7 No
5. Observed condition of component pumped:
xv\)
All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. Pumped 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
See above
Signature of Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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