HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 21 CLARK STREET 8/11/2025 Commonwealth of Massachusetts
City/Town of No. Andover
ry System Pumping Record
w ❑ 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 _--_--
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;
e an Name
SAME Town of Noah Andover
Address(if different from location)
City/Town State "I
Zil f"11.
Telephone Number
B. Pumping Record . » - = .�., , -Nnt
1. Date of Pumping oat 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank E<Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes Z No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of omponent pumped:
All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. System P mp Vehicle y:
License Number
_Name _
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
111-1
See above
Signature of Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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