HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 57 SOUTH CROSS ROAD 12/19/2025 Commonwealth of Massachusetts I Own of oft Andover
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System Pumping Record JAN - 5 20?Y Lo
For 4
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DEP has provided this form for use by local Boards of Health. 01thVt-an-46.i�
information must be substantially the same as that provided here. Before using thpisfarm, c "Swith 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 MA
use the return
key. City/Town State Zip Code
411-� 2. System Owner:
IAL'dUeg-jn �
Name
team
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record jsoo
1. Date of Pumping Date 2. Quantity pumped: Gallons
3. Component: Cesspool(s) Septic Tank 7 Tight Tank 7 Grease Trap
F71 Other(describe):
4. Effluent Tee Filter present? F7 Yes 'No If yes, was it cleaned? 7 Yes 7 No
5. Observed condition of component pumped:
CYY)2� All of this estimated
information is non-binding, valid y a—tt5e_time of pumpin2. Not responsible beyond the date above.
6. Syst11�roped By:
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewarfs Global Environmental, LLC
20 So. Mill St,, Bradford, MA Qj 835
See above
Signature of Hauler Date
See above
Signature of Receiving Faciiny(.,attach facilityreceipt) Date
t5form4.doc-11/12
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