HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 234 BRADFORD STREET 4/16/2026 Town of NoM Andover
Commonwealth of Massachusetts
�s m City/Town of No. Andover
Y -° 2026 MA
System Pumping Record
Vp Form 4 Hearth 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,
9
use only the tab __ ��- -Z-�_9
all
key to move your Address
cursor-do not No. Andover MA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
deb
Same
Name -
rearm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Coate 2. Quantity Pumped:
� G 11 allons
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 con ;tion of�mponent pumped:
All of this estimated
information is non binding, valid only at the time of pumping.,Not responsible beyond the date above.
& System Pumpe 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
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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