HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 29 CHERISE CIRCLE 11/12/2025 ,C\ Commonwealth of Massachusetts TOLAIn of North Andover
City/Town of JIL 0
System Pumping Record
Form 4 DEC - 2025
DEP has provided this form for use by local Boards of Health. Other ftr4res: gay l?§ yt the
information must be substantially the same as that provided here. Before using this f94 Y, "h 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 comw,jter,
use only the tab
key to move your Address
cursor-do not
use the return MA
key. City/Town State Zip Code
2. System Owner:
Name
Address(if different f—rom—location}
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: -.I Soo
Dat Gallons
3. Component: 7 Cesspool(s) Septic Tank 7 Tight Tank F7 Grease Trap
7 Other(describe):
4. Effluent Tee Filter present? 7 Yes 2'No If yes, was it cleaned? 7 Yes [] No
5. Observed condition of component pumped:
9, 0Q All of this estimated
information is non- onsible beyond the date above._
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
2 o, Bill St,,�Bradfo�rd, MA 01135
-Signature of Hauler Date
See�above�����
See above
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc-11/12
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