HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 114 BOSTON STREET 11/14/2025 1T0wn ,C',,,r Nloil'M Andover
�L\ Commonwealth of Massachusetts
City/Town of (DQr DEC - 12025
System Pumping Record
For 4
Hea,4`ho Department
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 com;.;,Aer,
use only the tab 1��-i Rc):�)� — - _—
key to move your Address
cursor-do not MA
use the return
key. City/Town State Zip Code
2. System Owner-
C)
Name
raitm
Address(if different from n)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: F7 Cesspool(s) 0/septic Tank 7 Tight Tank F7 Grease Trap
7 Other(describe):
4. Effluent Tee Filter present? [7 Yes No If yes, was it cleaned? F7 Yes 7 No
5. Observed condition of component puW ed:
OD Q All of this estimated
information is noD:bindin , id only at the time_ofumppla . Nat responsible beyond the date above.
6. Syste
m redff,
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 es? ill Pr*adford, MA 01835
?Mill
See above
Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc-11/12
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