HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 17 SUGARCANE LANE 11/10/2025 Commonwealth of Massachusetts T6wn of No�h An.dOver
City/Town of DEC
2025
System Pumping Record
Form 4
�-"";oat 4
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
key to move your Address
cursor-do not MA
use the return
key. City/Town State Zip Code
2. System Owner:
...................---------
Name
---I -........... ------ ------ --------
Address(if different from location)
City/Town State Zip Code
l"elephone Number
B. Pumping Record
1. Date of Pumping ......V� 2. Quantity Pumped:
Date Gallons
3. Component: El Cesspool(s) Septic Tank Fj Tight Tank 7 Grease Trap
Other(describe):
4. Effluent Tee Filter present? 7 Yes /o If yes, was it cleaned? F Yes-
5. Observed condition of component pumped:
All of this estimated
information isnon-binding, lid o I the in um Not responsible.b d the date 0\�e-
_ _ya a y at—_1L
6. System Pumped 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
20 So. Mill St., Bradford, MA 01835
----------
See above
Signature of auler Date
See above
signature of Receiving Facility(or attach facility receipt) Date
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