HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 62 WILLOW RIDGE ROAD 4/10/2026 Commonwealth of Massachusetts TOWn Of Nopth Andover
- City/Town of No. Andover
1A
System Pumping Record
Form 4,
E ii.tl9 'bdG � t
DEP has provided this form for use by local Boards of Health. Other forms may be use8, but t e
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.
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A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the 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:
tab
Same
Name
ts�
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date Gallons 2. Quantity Pumped: on .
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
Other (describe):
4, Effluent Tee Filter present? ❑ Yes eNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed cor,�dition of component pumped:
("ae All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. System Pumped B
Name Vehicle License 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 f r
....
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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