HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 124 TUCKER FARM ROAD 11/17/2025 �L\ Commonwealth of Massachusetts lbv,-� U�f
City/Town of kxD —G1fV-\W 4-r- t rt�i 4ndover
System Pumping Record
Form 4 DEC 2025
DEP has provided this form for use by local Boards of Health. Other fo be used, but the
0%
information must be substantially the same as that provided here. Bef6r Ing I
P c eck with your
local Board of Health to determine the form they use. The System Pumping Record nms e4ifted 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, a14
use only the tab 'L6
-----------
key to move your Address
cursor-do not MA
use the return
key. City/Town State Zip Code
2. System Owner:
P ---� . -- - .....................
ar�e -C-10v%-1,---C-An�
----------- ..........- ------------
Address(if different from location)
ty[Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ------— 2.
D'a'-te"' Quantity Pumped: ons
3. Component: ❑ Cesspool(s) ;Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ------------
4. Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? [] Yes [] No
5. Observed condition of component pumped:
All of this estimated
information is non-bLirlqjpg, varid at the time of �!jq SIble �e�qnq the date
te abov-e-.----
6. m4
System P ped 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. dford MA 01
See b
ature zof!41�5uler-n�14 -bate a7 iT ------ --------
See abole
Signature of-Receiving---Facility—(or attach—facility--receipt)------- Date
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