HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 857 CHESTNUT STREET 12/9/2025 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 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 lown of Nofth Andover
Important:When
filling out forms I• System Location:
on the computer, JAN 202� L�)
use only the tab -C
key to move your Address
cursor-do not MA
use the return City/Town state �w Depa
key, Km--enf
VQ 2. System Owner:
11111 de Name
Tc�d—re;-s(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
I Go
1. Date of Pumping Date 8 2. Quantity Pumped: 'Yallons
3. Component: 7 Cesspool(s) 'k.Septic Tank 7 Tight Tank F7 Grease Trap
F7 Other(describe):
4. Effluent Tee Filter present? 7 Yes 7 No If yes, was it cleaned? 7 Yes 7 No
5. Observed conditi f component pumped:
11 of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. Sys pnped By:
Name Vehicle License Number
AS Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewaits 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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