HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 230 LACY STREET 11/5/2025 Commonwealth of Massachusetts Town Of NoM Andover
City/Town of r)
System Pumping Record DEC - 12025
0 Form 4
Hp
DEP has provided this form for use by local Boards of Health. Other forms gp eQ0PA
information must be substantially the same as that provided here. Before using this form, cUlwyour
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 comp;,ter, 5�
use only the tab
key to move your Address
cursor-do not MA
use the return City/Town State Zip Code
key.
2. System Owner:
�aerattan
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Z 2. Quantity Pumped:
Date Gallons
3. Component: F7 Cesspool(s) n/-'Septic Tank F71 Tight Tank F7 Grease Trap
17 Other(describe):
4. Effluent Tee Filter present? F7 Yes [n�No If yes, was it cleaned? 7 Yes 7 No
5. Observed condition of component pumped:
0 C., , All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. System Pu d By:
Name Vehicle License Number
J&S Dev44ent 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
t5f0rM4.doc- 11/12
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