HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 247 FOREST STREET 6/1/2026 Town of North Andover
Commonwealth of Massachusetts
City/Town of No. Andover JULw° 26
System Pumping Recor
Farm 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
key to move your Address
cursor-do not No. Andover MA 01845
use the return
key. City/Town State Zip Code
2. System Owner: r
Same t
_Name
Address(if different from location) _
City/Town State Zip Code
Telephone Number
B. Pumping Retard _._..___.
62
1. Date of Pumping gate 2. Quantity Pumped: 41c ns
ly
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): _
4. Effluent Tee Filter present? ❑ Yes kNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
All of this estimated
information is noh-16inclllng,_ lid only at the time of pumping. Not responsible beyond the date above.
& System P m ed
.................................._....
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 Facil y, 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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