HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 274 FOSTER STREET 11/4/2025 Commonwealth of Massachusetts TOU ofNoti Andover
CityfTown of
DEC - I 2025
System Pumping Record
Form 4 Hoadl'lh Department
DEP has provided this form for use by local Boards of Health. Other forms may be used, but 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 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 XT-A
key to move your Address
cursor-do not MA
use the return City/Town State Zip Code
key.
2. System Owner:
Name
Address(if different from location)
Cityf%wn State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: F7 Cesspool(s) zSeptic Tank F7 Tight Tank F7 Grease Trap
F7 Other(describe):
4. Effluent Tee Filter present? 71 Yes No if yes, was it cleaned? F7 Yes F7 No
5, Observed condition of corn neat pumped:
7y-c:� All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. System MA :
- V - 10
Name Vehicle License Number
J&S Development Corp. d/bJa 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
t5form4.doc-11/12
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