HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 373 RALEIGH TAVERN LANE 6/2/2026 own of
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:\ Commonwealth of Massachusetts ndaver
x City/Town of No. Andover
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-_ System Pumping Record 7 2026
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be us AQ11
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, / g
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
�e
2. System Owner:
Same _Name
Address r�
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date GMons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -- -
4. Effluent Tee Filter present? ❑ Yes XNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped: T�
All of this estimated
information ._ .._.. bindM, valid only at the time of pumping. Not responsible beyond the date above
6. System Pumped By:
_---
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:
jStewart' Rece' in acility, 20 So. Mill St., Bradford, MA 01835
See above
nature of Hauer Date
Signature of Receiving Facility(or attach facility receipt) Da
te
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