HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 125 SULLIVAN STREET 5/7/2026 Commonwealth of Massachusetts g, City/Town of cr sae Of lVcrth Andover
System Pumping Record
Form 4 JUN 1 - 2026
DEP has provided this form for use by local Boards of Health. Other form ay be used, but the
information must be substantially the same as that provided here. Befcrellam"'fE7 nW nh e h your
u
local Board of Health to determine the form they use. The System Pumping Record t u8 to
i
the local Board of Health or other approving authority within 14 days from the pumping date n
accordance with 310 CMR 15.351.
A. Facility Information
important When
filling out forms I. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not MA
use the return
key. rn cizy/TcWn State Zip Code
2. System Owner:
Marne
racra
address(It different from location)
CltryTrown State Zip Code
elephons Number
B. Pumping Record
Date of Pumping gate Quantity Pumped: Gallons
7
3. Component: 7— Cesspool(s) /Septic Tank ill Tight Tank Grease Trap
7 Other(describe):
4. Effluent Tee F'ilter present? 7 Yes i Ne sf yes: was it cleared? 7, Yes I No
5. Observed Condition of compone—L pur�n ed:
YY5612 All of this estimated
,information is non-bindin2; valid Only at the time of QLAPing. Not resp6rsibie be and the date above.
B. System Pumped BY:
Name Veil4'--ie License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7- Lo—tion when contents were disposed:
Ste-warts Global Ervironmentai, LLC
.20 So. Mill $Mclford, MA 01335
See above
Signature r Date
Signature of e i g t y Ora, oh— 11.1,yrece; a�e above
Date
t5f0rM4.doC-11/1 p
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