HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1015 JOHNSON STREET 3/18/2026 Commonwealth of Massachusetts Town Of N AndOver
City/Town of No. Andover
System Pumping Record APR 7 202
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may "" }
information must be substantially the same as that provided here. Before using this form, check fh 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 only the tab / 0 05
__... -
key to move your Address
cursor-do not No. Andover MA 01845
use the return __
key. City/Town State Zip Code
2. System Owner:
Q
Same ,f.�
Name
rearm
Address(if different from location)
_ _.- _ __. ....... .......
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 11ate 3/( 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) 2 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 only at the time of pumping. Not responsible beyond the date above.
6. System P ped B : ,
Name Vehicle Li nse Number
J&S Development Corp. d/b/a Stewart's Septic
Service, 58 So. Kimball St., Bradford, MA 01835
7. Location where contents were disposed:
Stewart's Receiving Facility, 20 So. Mill St., Bradford, MA 01835
See above
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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