HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 43 OXBOW CIRCLE 4/23/2026 �L\ Commonwealth of Massachusetts TowI7 of NOrM AndOVer
City/Town Of L-Nalqi,&�er- MAY - 62026
System Pumping Record
Form 4
De
DEP has provided this form for use by local Boards of Health. Other for:ns may bePAq%W
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. 711e System Pumping Record must be submitted to
the local, Board of Health or or-her approving authority withir, 14 days from the pumping date in
accordance with 310 0MR 15.351.
A. Facility Information
importan When
filling out forms System Locaton:
on the computer,
use only the tab 43 Ot,—vbw -Ckrt�
key to move your Address
==r-do not
use the return
MA
key. urn
Oftyi7owr; Site Zip code
2 E,' --t 9 rn, 0 w-n 9:
$Gt4xaj 16
Address(1,dif-e-ert from loc—aton)
City/Town S=te Zip Code
Num
B. Pumping Record
! purnp!.ng date 0 2. Quan4fty Purnped: o
Gallons
3, Component:
21 /seotc Tank h t"T"a nk 71 Grease Trap
17 Ct!19r(describe):
4. Effluent Tee Filter present? Yes i ' No If yes: was it cieened? 7 yes 71 No
5. Observed condition OT corroon-ent purnpe
Ali Of this estimated
1-1O1n-bindl, O,,.va!id only at th-a tir.,je Of M—Qlng, Not reSP 0,71,S i bi e b
e Qnd the date above.
C,
Systern d By:
Vehicie License Number
rn _d By-' ijj_j.
W--XD)FC,eiop,rnent Corp, d/b/a Stewart's SeD;,,ic
Service
7. Location where contart_wets olisposeol:
stewWl's Global Env�ronmentai, LLC
0
20 01836
above
u4sr I
-�-t,-, Inc
9 F a CIT 11 ty
abOve
System PLrnpirg Record-Page 7 Of I