HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 91 VEST WAY 9/26/2025 I
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Commonwealth of Massachusetts
City/Town of No. Andover Over
OCT T
System Pumping Record 2025
............. ❑ Form 4
DEP has provided this farm for use by local Boards of Health. Other forms may be us
information must be substantially the same as that provided here. Before using this form, check QiWur
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 City/Town State ....
key. Zip Code
2. System Owner:
rob J I r '
Name
Address(if different from location) _
City/Town State Zip Code
Telephone Number
B. Pumping Record
gg
1. Date of Pumping Date 2. Quantity Pumped: Gallons
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:
gm "D All of this estimated
information is non-binding, val d my at the time of pumping. Not responsible beyond the date above.
6. Sy umped 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
Signatu Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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