HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 805 SALEM STREET 8/11/2025 0 1 uwn Of North Andover
Commonwealth of Massachusetts
City/Town of AUG 112025
System Pumping Record F Heallh D
orm 4 ePc2rtMent
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
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 CIVIR 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 MA
use the return
key City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Zip Code
Telephone Number —� _--
B. Pumping Record
1❑
Oo
1. Date of Pumping 2. Quantity Pumped:
Date Gallons'r
3. Component: 7 Cesspool(s) Septic Tank 7 Tight Tank ❑ Grease Trap
7 Other (describe):
4. Effluent Tee Filter present? 7 Yes 27No If yes, was it cleaned? 7 Yes 7 No
5. Observed condition of corn nent pumped:
67,c"C7�7_- All of this estimated
information is non-binding vaiid beyond the date above.
6. System Pu pe B
I a Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewart's Receiving Facility,_2O So. Mill St., Bradford, MA 01835
See above
Signature of Hauler Date
See above
Signature of Receiving Facility(or attach facility�eceipt) Date
t5form4.doc-11/12 System Pumping Record-Page 1 of 1