HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 146 FARNUM STREET 7/11/2025 Commonwealth of Massachusetts Town Of NO,1h AndOver
City/Town of.oD. 4(N&A_kr
System Pumping Record AUG 112025
Form 4
DEP has provided this form for use by local Boards of Health, Other h
information must be substantially the same as that provided here. Before using tRi's(g#rAr,%1&1th 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 14Q
key to move your Address
cursor-do not MA
use the return
key. City/Town State Zip Code
2. System Owner:
reb
e—
Name
Address(if different from location)
City/Town State Tip-Code
Telephone Number
B. Pumping Record
d 0 Oro
1. Date of Pumping 2. Quantity Pumped:
Dat Gallons
3. Component: F7 Cesspool(s) n/Septic Tank 7 Tight Tank 7 Grease Trap
7 Other(describe):
4. Effluent Tee Filter present? 7 Yes /No If yes, was it cleaned? ❑ Yes 7 No
5. Observed condition of ponent pumped:
r
'T All of this estimated
information is_non-bi�ndin valid only at the time of pumpiN. N2tre beyond the date above.
6. System P mpe �y.
_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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