HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 53 OLD CART WAY 9/24/2025 Commonwealth of Massachusetts ollt� doVer
w City/Town of No. Andover OCT
System Pumping Record 62025
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be use
information must be substantially the same as that provided here. Before using this form, chec th 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, c r
use only the tab - _ ---- --- -- ---- - --- - - - ------ _3 . . I/d
key to move your Address
cursor-do not No. Andover MA 01845
use the return -- --__ - _-.__ ______ _-_.—
key. City/Town State Zip Code
VQ 2. System Owner:
Name
MLM7
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping - 2. Quantity Pumped: -1
DaGallo 11 ns
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 condition 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. System Pumped By:
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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