HomeMy WebLinkAbout2 interior grease traps - Septic Pumping Slip - 18 HIGH STREET 2/3/2022 Commonwealth of Massachusetts RECEIVEC
W City/Town of No. Andover
System Pumping Record FEB 0 3 2022
Form 4 TCWN OF WJNTH ANDOVEF
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: /(7
on the computer,
use only the tab J
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
�d� Dyt
Name --
�rn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gall JJ
2
ns
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank Grease Traps
/❑ Other(describe): l/? n c�'—
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By: /&J�4
Name U Vehicle License Number
Stewart's Septic 58 So. Kimb I St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill St., Bradford, MA
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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