HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 300 DALE STREET 9/15/2025 Town
Commonwealth of Massachusetts
City/Town of No. AndoverOc T
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4 System Pumping Record
Form 4
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DEP has provided this form for use by local Boards of Health. other forms may be used, but en
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 taba p
key to move your Address
cursor-do not No. Andover MA 01845
use the return
key. City/Town State Zip Code
Y�
2. System owner:
Name
ftddY!
Address(if different from location)
City/Town State ZiagCode
Telephone Number
B. Pumping Record - -_
1. Date of Pumping gate 2. Quantity Pumped: lon$
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ other(describe).
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. observed co dition of component pumped:
All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. S ��ump�
By:
N 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 gate
See above
Signature of Receiving Facility(or attach facility receipt) Date
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