HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 20 SAW MILL ROAD 8/28/2025 Commonwealth of Massachusetts Town of NO tlAndover
r City/Town of No. Andover
System Pumping Record SEP
f 2'2025
Form 4
7M
DEP has provided this form for use by local Boards of Health. Other fc �, he
information must be substantially the same as that provided here. Before using"this 0h 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, "Zo
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:
VVV,
. rob
Name
retwn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped: Gallo
3. Component: ❑ Cesspool(s) Septic Tank ❑ 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, mponent pumped:
All of this estimated
information is non-binding, valid only at the time of pumping_Not responsible beyond the date above.
6. System um By: I,
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewart's Global Environmental, LLC
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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