HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 38 STONECLEAVE ROAD 5/27/2026 Commonwealth of Massachusetts Town �1 Norfl�i Andover
City/Town of L A A
System Pumping Record JUN 1 2026
Form 4
Healv,i
DEP has provided this form for use by local Boards of Heaith. Other forms may
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. T he 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
imwtaft When
filling out forms 1. System Location:
on the computer, -1
use oniy the tab Q?
key to move your
cursor-do not
use the return MA
key. State lip--ode
2. Systern, Owner:
,address(11 dt ftrent from location;
Cit YC Own State Zip Code
Teleeshone Number
B. Pumping Record
Date of Pumping 2. Quantity Puirn.paid:
Ga!ions
3. component, cesspool(s) 7 Tank 7, Grease Trap
I 61 -_Iec�tic Tank I Tight
7 Other(describe):
4. Effluent Tee Filter present?
Kyes No Yesz was it ciearied? yes 71 No
5. Observed condition purnped:on Of co
informatio 11 of this estimated
S. Systern, Pumped By: -.at,tl'6 t-'Me 0, PurrQIng. Not responsible be and :l f@ date above.
''I (
Name
Number
J&6 Deveicoerit Corp. d/b/a S� War:,s SeD� ve�,Icie License
m
7- Location where It,
were
diapo a6d:
S'ewsrfs Global Envi nrnentai, LLC2So. Mi St_ orc�
74
See above
signature of receiving Facljjfty(or a ct 4�c Jfty racj.ict) see above
t5f0rm4420C-11/12
System PUMPFng Record•Page 1 Of I
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