HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 64 OLD CART WAY 4/3/2026 Commonwealth of Massachusetts Toy 'x Wh Andover
-Y MAY 6 205
City/Town of L P:
System Pumping Record
Form 4 Fle�,J'Lh 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 computer,
use only the tab 1 ,., k+ OIL C-A i'"A
key to move your Aaftss
cursor-do not MA
use the return
key. CityfTown state Zip Code
2. System Owner:
�D(-A-C
Address(if different from lotion;
cltyfrown state Zip Code
Telephone Number
B. Pumping Record
1 D
- . 'J J,:�jc-."�Cp
t ate of Pumping Date -- 1 2. Quantity Pumped:
aligns —
3. Component: ❑ Casspooi(s) -17 �k 71 Grease Trap
'A Septic Tar 7, Tight Tank
F7 Other(describe):
4. Effluent Tee Filter present? Itz Yes 71 No 114 yes, was it cleaned? J&a Yes 7 No
5. Observed condition of component pumped:.
Q,o 0 All of this estimated
information is non-bindinQ, valid,&y at the time of pumping. Not responsible be and the date above.
6. System Pump —
Name Vehicie License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where Contents were disposed:
Stiewerts Global Environmental, LLC
20 So. Mill St A 01835
11�dlo,-d�, M
See above
signature of Hauier Date
See above
Sig
nature of Receiving Facility(or attach facility receipt) Date
t5f0rM4.doC- 11/12
System Pumping Record A page I of 1