HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 35 CHERISE CIRCLE 11/12/2025 �L\ Commonwealth of Massachusetts Town Of A1611h
City/Town of k)c) Andover
System Pumping Record
Form 4 OEC - .12025
DEP has provided this form for use by local Boards of Health. Other for rhaj*,
ad, but the
information must be substantially the same as that provided here. Before using ail D' with your
local Board of Health to determine the form they use. The System Pumping Record must be d 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
reman
-------
Address(if different from location)
CityCTown State Zip Code
Telephone Number
B. Pumping Record
00
1. Date of Pumping 2. Quantity Pumped: ................ ..............
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank F7 Tight Tank 7 Grease Trap
7 Other(describe): ---------
4. Effluent Tee Filter present? 7 Yes iNo If yes, was it cleaned? 7 Yes 7 No
5. Observed condition of component pumped:
] ()C)c, All of this estimated
information is-non-binqtn�'onlv at the time.2LRy_ tq. Nqt_respqnsit: ebeyond the date above.
6. System Pumped By:
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
T Location where contents were disposed:
Stewart's Global Environmental, LLC
20 So. Mill St., Bradford, MA 01835
h a's See above
.......... ...............
Signature of Hauler Date
See above
§.-ig`n aiure-ofRece-i-vi-ng—Fa-c-i-li"t-y--("o-r-,-a,t-tach—facilit-,y",-r,-ec—eipt) Date
t5form4.doc- 11/12 System Pumping Record-Page 1 of 1