HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 89 DUNCAN DRIVE 2/2/2026 Commonwealth of Massachusetts
City/Town of ja(,;l Town of Nofth Andover
System Pumping Record
Form 4 FEB - 2 2026
DEP has provided this form for use by local Boards of Health. Other fo s may be used, but the
information must be substantially the same as that provided here. Bef-CR sing thi-15_tg I your
,MTS;Ibe slu ed to
local Board of Health to determine the form they use, The System Pumping Record N#1
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
2. System Owner:
�A L 0-cic-i(,2
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Quantify Pumped: JP�nz
DateGallons
3. Component: F7 Cesspooi(s) OSeptic Tank 7 Tight Tank 7 Grease Trap
F7 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:
ryY� All of this estimated
information is non-bindin aid onl at the time of um in . foot responsible beyond the date above.
6. Sy roped 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
�
01835
MA
See above
Signatu f Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Crate
t5fOrM4.doc-11/12
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