HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 122 FOREST STREET 1/13/2026 Commonwealth of Massachusetts 1dWn of IVOrth Andover
City/Town of ., . a Ndc)oQj— 2 2026
System Pumping Record
For 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, bufAr
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
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:
L &
Name
mon
Address(if different from location)
City/7own State Zip Code
Telephone Number
B. Pumping Record
C 00
1. Date of Pumping Date '11,3 1 1 2. Quantity Pumped: Gallons
3. Component: 7 Cesspool($) 2111"S' eptic Tank F7 Tight Tank F7 Grease Trap
7 Other(describe):
4. Effluent Tee Filter present? F7. Yes F7 No If yes, was it cleaned? 7 Yes 7 No
5. Observed co dition of component pumped:
-T All of this estimated
information valid only'a't the time of purnpin . Not responsibie beyond the date above.
m .-6. Syste um By
Name �J 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 01835
See above
-�fgyture of HaulerDate
- See above
Signature of Reoelvmg Facility(or�atta.hfcfflty receipt) Date
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