HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 107 GRANVILLE LANE 5/14/2026 t Not Andover
�L\ Comnionwealth of as 'achusetts
n City/Town of JUN I - 2026
System Pumping Record
Form 4 H'V90 Department
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DEP has provided this form for use by local Boards of Health. Other, may be used, but the
informaton must be substantially the same as that provided here. Before Using tis 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 Vlthir, 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
important When
filling out forms I. ` yst Location:
on the Computer, r C"n use only the tab
key to move your Achress
cursor-do not
use the return 1 0 MA
key- Oftyi7c)fvr, state zip Cade
2. Syste�mn Owner:
Name i
Address(11 dffferent from lomdon)
City/Town 5 a e Zip Code
etep,',one Number
B. Pumping Record
'
.4 5 Date of Pumping Date, 2. Ciumnt-4,tv Pumped: Ga!lons
3. Component: 7 Casspooi(s) Tank
I I Tight Tera 71 Grease Trap
Ot her(describe):
.........
4- Effluent Tee Filter present? 7_7 Yes No if yes: was it cleaned? El Yes 17 No
5. Observed condlition of omponent PUMDed.
info r. 0 :� All Of this estimated
7ation is i-lon-binding, valid only at the Of PUMDing. Not reSronSlb1C- beyond the date above.
6. �System Purnped By:NsT de �4; 1
V V Veilicie License Number
J&S Developrnerit Corp. d/b/a Stewart's Sepid
service JO
7. Loce'don where contents were di�pdsea:
SteWart,s Global Environmental, LLC
20 So. Mill--t., Sradfor,4, . 01836
See above
D'S's
See above
System Pumping PMCOrd-'age 1 of 1