HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1577 SALEM STREET 11/28/2025 ropM
L Commonwealth of Massachusetts aI
. _ over
_ - r City/Town of No. Andover
a
System Pumping Record ` 2025
Form 4
DEP has provided this form for use by local Boards of Health. Other forms m/ay ut the
information must be substantially the same as that provided here. Before using this for th your
local Board of Health to determine the form they use. The System Pumping Record must be Mmitted 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, c
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
x�
2. System Owner:
..__ __-
Name
ra
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
All of this estimated
information is non-binding, validjnly 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,So7-% tt-St-.743r .dford, MA 01835
See above
Signature of Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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