HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 74 FULLER ROAD 10/24/2025 Town
Commonwealth of Massachusetts
City/Town of No. AndoverNOV 10 2025
f 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, bu
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 farms 1. System Location:
on
an the computer,
use only the tab
key to move your Address
cursor-do not No. Andover MA 01845
use the return key. City/Yawn State Zip Code
2. System Owner:
r�
Nam 11 e _
ra�wn
Address(if different from location)
City/Town State Zip.Code
Telephone Number
B. Pumping Record _
1. Date of Pumping Date 2. Quantity Pumped: I&allons
3. Component: ❑ Cesspool(s) [ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): --
4. Effluent Tee Filter present? ❑ Yes 2 No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
oQ 8 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:
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 Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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