HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 162 STONECLEAVE ROAD 7/6/2026 Commonwealth of Massachusetts of NorthAndover_. :w
(w City/Town of No. Andover AUG _ 4 2026
1"n System Pumping Record
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< Form 4
. :.. Health 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 i cte�et,�"-e
key to move your Address
cursor-do not No, Andover MA 01845
use the return
key. City/Town State Zip Code rob:1 -
2. System Owner:
Same r1k 4-5,
Name
rerun
Address(if different from location)
City/Town State Zip Code
Telephone Number
_.�_.....__...........
_ ..
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: F� Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes Qf No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
All of this estimated
information is non-binding, lid only at the time of pumping. Not responsible beyond the date above.
6. Sy 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
_S 11 ign ure of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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