HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 90 TUCKER FARM ROAD 5/21/2026 GL\ Commonwealth of Massachusetts TOWn cf Nofth Andover
City/Town of
JUN I - 2026
System Pumping Record
Form 4
DEP has provided this form for use by locai Boards of Health. Ctherforrrisnniay be used, but the
information must be substantaiiy the sarne as that provided here. Before using tis form, check with your
local Board of Heath to determine the form they use. The System Pumping Record must be submitted to
the iocai Board of Heath or other approving authority witin I A days from the pumping date in
accordance with 310 CMR 13.331.
A. Facility Information
Importaft When
filling out forms I- System Location:
on the computer,
use onP r the tab E-Ct,YrYN
key to move your Address
cursor-do not
use the return MA
key. Or'Y/-rowr. Stale Zip Code
&07_�
2. Systern, Owner:
R.,
Address Of dtf-went from location)
Cify,7vwn State Zip code
e1sphons N1.1"noer
B. Pumping Record
D2te of Purnping D 2. Qusnt�; Pumped:Puped�
ata' -Y
3. Component: SepticTank i T;ght Tank _71 Grease Trap
El Cther(describe):
4. Effluent Tee Filter preseri.zL'? it
VeS; W--s i Cleaned? 7
E3 yes 2�1 No — Yes F7 No
5. Observed conditOn Of Component purn.oed*
(7
Intorma'don IS llon-bindinQ vajid c'F tNs estimated
t th e 4:in I e of;D urr.Q i n q foot rises be and the date
6. Systern, PuMped Y: RorSibie b /Ord the date above.
eh Le be
J&S Deveiopment.Corer. dib/a Stewart's Sep-tic V icie icens Nium r
Service
7- Lac2tjon-where contents were disposec,:
Stev,Mfts Gicbef EnvirOnrneritai, LLC
20 L91 MA o i a 3.5
See
above
Sign tore of R.+ceivrng Pacitiiyy(or
c,' .01I...Y rec 66 above,
,,
t5f0rM4.do4—11/12
system Pump,,19 Record-Page 1 of 1