HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1551 OSGOOD STREET 5/8/2026 Commonwealth of Massachusetts TUM of Noifth Andover
City/Town of No. Andover
w° System Pumping Record ,1UN I - 2026
a
Form 4
DEP has provided this form for use by local Boards of Health. Other for+41.
information must be substantially the same as that provided here. Before usinthis or �'datyour
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, ( f
use only the tab f
key to move your Address
cursor-do not No. Andover MA 01845
use the return
key. City/Town State Zip Code
VQ 2. System Owner:
Same l "�l c' ��� � . t1_ x,1U;,r
Name
�iA
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date __ ___ 2. Quantity Pumped: 11
Ga 11 llons 11111111
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 condition of component pumped:
41—c 1/ 3
� ° (,W) All of this estimated
information is non-binding, valid only at the time 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, 58 So. Kimball St., Bradford, MA 01835
7. Location where contents were disposed:
Stewart' _Receiving Facility, 20 So. Mill St , Bradford, MA 01835 Re _
See above -
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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