HomeMy WebLinkAboutTight Tank - Septic Pumping Slip - 21 CLARK STREET 7/10/2026 Commonwealth of Massachusetts Town of North Andover
a� City/Town of No. Andover
w System Pumping Record AUG - 4 2026
❑^ =_- ❑ Form 4
DEP has provided this form for use by local Boards of Health. Other fo q`rAi tP@ 1-Rqnt
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 only
computer, �
use only the tab r''�"' l'-�'
key to move your Address
cursor-do not No. Andover MA 01845
use the return
key. City/Yawn State Zip Code
2. System Owner:
VQ
Same
Name
/BtN77
Address(if different from location)
City/Town State Zip Code
Teleph one Number
B.T Pumping Record --.
1. Date of Pumping 2. Quantity Pumped:
Date 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 c ponent pumped:
All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. System Pu d 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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