HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 691 FOREST STREET 8/18/2026 Commonwealth of as "achusetts Town of NoO Andover
City/Town oPD -0-f -V16-a3Q-r SEP 3 2026
System Pumping Record
Form 4 Health De cl gn,
g
DEP has provided this form for use by local Boards of Health. Other forms may be seMu.. a
information.n must be substantially the same as that provided here. Before using this fora, 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 frorn tle pumping date In
accordance with 310 CMR 15.351.
A. Facility Information
important When
filling out f0mi's I. Systern Locavon.,
on the Computer, 1-1
use only the tab
key to move your Address
cursor-do not MA
use the return city/70wr. state ZIP coda
key-
2. Systern Owner:
?Marne
rman
Address(1, different rmrn locaton)
0'.ty/Town State Zip Code
?eleo ore plumber
B. Pumping Record 15(Dro
4
t. Date of Purn�ming Date ' 1 1 2. Quantity Purnped: Ga!Jons
3, ccrnponert: 7 Cesspool(s) -KSeptic Tank 7 Tight Tank Grease Trap
7 Other(describe):
4. Effluent Tee Filter present? 7 Yes No f yes, Was it Cleaned? 7 Yes 17 No
5. Observed condition of cornponent PUMOC-d.
1 0 o-f ell of Vils estimated
iffor-natior is non-bindl,
oni at Fade e of pumping. Not responsible be and the date above.
S. System Puln r'BA
Vetlicie License Number
j&S Deveioprnerlt Corp. d/b/a Septic
St wart's
ES tic
Service
7. Loca-tion.where contents were disposed:
St9warfs Giobai Environmental, LLC
�'O SO f3 ord MA 01835
See above
Date
See above
519-11ature of Racejvjfng F801jity(or-
atzac?-'nacll.-y Date
t5ftrm4-doe.11/12
Systarn Pur-nprng Reocd.pace 1 of 1