HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 114 PENNI LANE 4/1/2026 �L\ Commonwealth of Massachusetts Town of Nofth Andover
F, City of u-
N MAY 6 ZO
System Pumping Record
Form 4
Health 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 'Panf-\,
key to move your Address
cursor-do not MA
use the return City/Town state Zip code
key.
0�
2. Sy am Owner:
(��
Name
Address(if different from location)
City,7own State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Dafe- Gallons
3. Component: F7 Cesspooi(s) :tl8eptic Tank 7 Tight Tank 17 Grease Trap
F7 Other(describe):
A
4. Effluent Tee Filter present? 7 Yes 0 If yes, was it cleaned? 71 Yes 71 No
5. Observed condition of component pumped:
M All of this estimated
Information is non-binding, valid only at he e of pumping. NOT responsible beyond the date above.
6. System Pumped By:
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Loc2tion where contents were disposed:
Stewart's Global Environmental, LLC
20 So. Mill St., Bradf MA 01835
11-3 , See above
Sig at f Haul r Date
See above
Si ature o R'CeMng Facil* (or attach facif receipt) Date
r y
t5forrn4.doc-11/12
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