HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 10 WOODCHUCK LANE 11/4/2025 TOV
Commonwealth of Massachusetts 111 NOrth Andover
City/Town of No. Andover ❑
System Pumping Record 2
Form 4
d .
DEP has provided this form for use by local Boards of Health. Other forms may e�U
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.
_........-- __.._-----._..__ ____. ..................._-_...
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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 No. Andover MA 01845
use the return key. City/Town state Zip CadeOki _
2. System Owner: y �"
Name
ret�n
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
tf (� '
1. Date of Pumping rate 2. Quantity Pumped. ailons
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 con iti n of component pumped:
All of this estimated
informatio is nori-binding,,_valid only at the time of pumping. Not responsible beyond the date above.
y P d By:. st um
_.._._ ......."qua' ` M ....._ _..._.._._. ...__._. _ ....._ .... ......
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 So. Mill St., Bradford, MA 01835
... ---
See above
Signature of Hauler date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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