HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 467 SALEM STREET 6/12/2026 Commonwealth of Massachusetts Town Of North Andover
q� („ City/Town of No. Andover
System Pumping Records 72026
Form 4
DEP has provided this form for use by local Boards of Health. Other ormup
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 ` 0Vj
key to move your Address
cursor-do not No. Andover MA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
Same1 ✓� _
Name
✓s1r�n
Address(if different from location)
--- ..... ................................. --
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date CIlons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? F� Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumpe
. All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. S t71 3
�Pum d �
_.
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:
ewairts ReceMng„ o� t Bradford, MA 01835
See above _
Sig nature,,bf Mauler ^ Date
Signature of Receiving Facility(or attach facility receipt) Date
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