HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1267 OSGOOD STREET 11/12/2025 Town Commonwealth of Massachusetts Of NO*AndOver
City/Town of jzx�, A c6o.)er
System Pumping Record Dr-C
Form 4
DEP has provided this form for use by local Boards of Health. Oths4erT ,,m ay,,be used, but the
information must be substantially the same as that provided here. Before usini4i'llpfalp" with your
local Board of Health to determine the form they use. The System Pumping Record must bLetmitted 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 I Q(0
key to move your Address
cursor-do not MA
use the return City/Town State Zip Code
key.
I System Owner:
Prx r V-0 C,
Name
Address(H different from location)
-d—ityffo—wn State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Datel I -G&Ions
3. Component: F7 Cesspool(s) j Septic Tank F7 Tight Tank F7 Grease Trap
F7 Other(describe):
4. Effluent Tee Filter present? F7 Yes No If yes, was it cleaned? 7 Yes F7 No
5. Observed condition of component pumped:
C-;10,51 All of this estimated
information is non-binding, valid only at the time of PuMpj_ng, Not responsible beyond the date above.
6. System = C,
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewart's Global Enviro e
1 1 :�--7 .
2!0 t.,-BradUl
See above
Signature 0 auler Date
-See above
Signature of Receiving Facility(or attach facility receipt) Date
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