HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 356 REA STREET 11/20/2025 Commonwealth of Massachusetts Town Cf N O tiN Andover
City/Town of No. Andover
System Pumping Record
X.
a
Form 4
s 0 a;
DEP has provided this form for use by local Boards of Health. Other forms may be used, but het
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 computer,
use onlythe tab - --- __
key to move your Address -
cursor-do not No. Andover MA 01845
use the return -----_ _--
key. City/Town State Zip Code
2. System Owner:
W
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
iso
1. Date of Pumping G
2. Quantity Pumped: _
date alIons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
All of this estimated
information is non-binding, valid pn y at tf e time of pumping_ Not responsible 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
_ .4 o fCC�ittli St-1:,—Wa dford, MA 01835
See above
Signatur auler Date
above
See abo
- ---- _ _ .......... ---
Signature of Receiving Facility(or attach facility receipt) Date
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