HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1785 SALEM STREET 10/24/2025 &1\ Commonwealth of Massachusetts Town of North Andover
City/Town of n6c$-)Q�- NOV 1, 0 2025
System Pumping Record
Form 4
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DEP has provided this form for use by local Boards of Health. Other ok
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 com-uter, j-1
use only the tab
key to move your Address
cursor-do not MA
use the return City/Town State Zip Code
key.
1 System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record J000
1. Date of Pumping 2� Quantity Pumped:
Date Gallons
3. Component: F7 Cesspool(s) XSeptic Tank F7 Tight Tank F7 Grease Trap
F7 Other(describe):
4. Effluent Tee Filter present? F7 Yes NO If yes, was it cleaned? F7 Yes F7 No
5. Observed condition of compon t pumped:
:) I All of this estimated
information is non*inding, valid only at the time of um in . Not responsible beyond the date above.
6. Syst Pu 0,--I'll I (
O..*�
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—HauVer -----
Date
See above
Signature of Receiving—Facility(.r at-,.on facility Date
t5form4.doc- 11/12
System Pumping Record•Page 1 of 1