HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 166 REA STREET 10/29/2025 Commonwealth of Massachusetts
g City/Town of No. Andover
System Pumping Record
Farm 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
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 tab /
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 .
r�rtan
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
c
1. Date of Pumping a11 11 ...2. Quantity Pumped:
ate allons
�µ
3. Component: ❑ Cesspool(s) I/Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): _ ......
W
4. Effluent Tee Filter present? ❑ Yes 4INo If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
Y 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
a ure a � See above
puler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1