HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 65 OLD CART WAY 12/3/2025 �L\ Commonwealth of Massachusetts
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System Pumping Record
For 4
DEP has provided ths form for use by local Boards of He2ith. 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 Town of Nofth Andover
filling out forms 1. System Location:
on the computer,
use only the tab i A O
key to move your Add ress 1 4 u 6P
cursor-do not MA
use the return
key. City/Town State Zip Code
1 System Owner: C-Partment
Name
Address(if different Trom location)
CityfTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping a 2. Quantity Pumped:
Date Gallons
3. Component: F7 Cesspool(s) Z'-'Septic Tank F7 Tight Tank F7 Grease Trap
F7 Other(describe):
4. Effluent Tee Filter present? [I'<es 7 No If yes, was it cleaned? Z-,Yes 7 No
5. Observed condition of component pumped:
All of this estimated
information is no beyond the date above.
6. System rd
Name
Vehicle License Number
J&S 6/velopment Corp. d/b/a Stewart's SepticService
7. Location where contents were disposed:
Stewart's Global Environmental, LLC
20 So. Mill St., Bradford, MA_ql 835
See above
§Fdr�-a-ture of Ha—uler Date
See above
Signature of Receiving-Facility(or attach facility receipt) Date
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