HomeMy WebLinkAboutTight Tank - Septic Pumping Slip - 21 CLARK STREET 6/12/2026 Commonwealth of Massachusetts Town of Wh Andover
City/Town of No. Andover JUL 2026
° System Pumping Record
❑ ❑ Form 4Health Department
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
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. 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,
use only the tab
-
key to move your Address
cursor-do not No. Andover MA 01845
use the return __ - - -- -- - -- -- --- -- ........
key.
City/Town State Zip Code
Q2. System Owner:
Same Gcrr�. (/❑ "
Name
return
Address(if different from location)
- ------- - - - -- -
City/Town State Zip Code
Telephone Number
B. Pumping Record _
1 -- �.
1. Date of Pumping Date -- --- 2. Quantity Pumped: Gallons
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:
All of this estimated
information is non bindln , valid only at the time of pumpinR. Not responsible beyond the date above.
6. S�%e. 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's Receiving Facility, 20 So. Mill St Bradford, MA 01835
._..._.
... .._ ---- . ._._ - __. See above
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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