HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1995 SALEM STREET 2/2/2026 Commonwealth of Massachusetts
City/Town of LL AAAwar Town of No�h Andover
System Pumping Record
Form 4
FE8 2 Z2l�
DEP has provided this form for use by local Boards of Health. Other forms may be,usgut 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 Rp� w=tbe submitted to
the local Board of Health or other approving authority within. 14 daylsprc%!thePN�4 7- t
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab J i—
key to move your Address
cursor-do not MA
use the return
key. City/Town state Zip Code
2. System Owner:
kc.-NA3,
Name I
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:DateGallons
3. Component: F7 Cesspool(s) ff"Septic Tank 7 Tight Tank 17 Grease Trap
L7 Other(describe):
4. Effluent Tee Filter present? F7 Yes 7 No If yes, was it cleaned? F7 Yes 7 No
5. Observed condition of component pumped:
(", All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. Syste um ed
17 Z,
Nam
e Vehicie License Number
evelopment Corp. d/b/a Stewart's Septic
S c ice
a ice
7. Location where contents were disposed:
Stewart's Global Environmental, LLC
20 Sc. MilI St., Bradford, MA 01835
See above
Signature of Hamer Date
- See above
Signature—of P—Receiving Facility(or�attachfacljjty receipt} Date
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