HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 30 PENNI LANE 4/15/2026 Commonwealth of Massachusetts Town of Not Andover
cu r City/Town of No. Andover MAY - 6 2026
w° System Pumping Record
Form 4 , "h, Depe"ment
DEP has provided this farm 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 t ob r Address
Y Y
cursor-do not No. Andover MA 01845
use the return -_ _—____
key. City/Town State Zip Code
2. System Owner.-
Same
Name
return
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date G 11 allons
3. Component: ❑ Cesspool(s) �eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Lbko If yes, was it cleaned? ❑ Yes No
5. Observed condition of component pumped:
cr All of this estimated
Informatl s on-binding, valid only at the time of pumping. Not responsible beyond the date above.
I
- ----
& System Purl ped By: W
c ._
_ - - _
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:
Ste "s R"ecely-ng� ty, 20 So. Mill St., Bradford, MA 01835
See above
ignature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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