HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 21 CLARK STREET 8/10/2026 Commonwealth of Massachusetts Town of North Andover
_ City/Town of No. Andover
w° System Pumping Recordozs
Form 4 Health e -�
CEP has provided this form for use by local Boards of Health. Other forms may be DA
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 farms 1. System Location:
on the computer, y ( 7
use only the tab "'. °� (.. z ;
key to move your Address
cursor-do not No, Andover MA 01845
use the return
key. city/Town State Zip Code
2. System Owner:
Same ( ,Pq41t 1` l G �
Name
return
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
6q5D
1. Cate of Pumping
at -- 2. Quantity Pumped:
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe): _ .... ...
4. Effluent Tee Filter present? ❑ Yes 2 No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
C All of this estimated
information is non-binding, vali a y at the time of pumping Not responsible beyond the date above.
6. System Pumped B
t
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
;i Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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