HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 361 CHICKERING ROAD 8/4/2025 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
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 CMR 15.351.
A. Facility Information Town of NWi Andover
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 5 ce 1 0 SEP 2:2025
key to move your Address
cursor-do not
use the return MA
key. City/Town State Health DepAi"ent
2. System Owner:
LCL01.rn(-YO.,
Nam
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: J600
Datv- Gallons
l(S
3. Component: F7 I l(s) �- SepticTank 7 Tight Tank F7 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:
All of this estimated
informationresponsible beyond the date above.
I'. Sy'r ped 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
S,gnatYr,'-of�H.. Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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