HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 18 HIGH STREET 9/5/2022 Commonwealth of Massachusetts RECEIVED
u W City/Town of No. Andover SEP o 6 2022
° System Pumping Record TowN of NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
' M
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
fining 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 Cityfrown State Zip Code
key.
2. Sys Owner:
l5?y9-rr)
Name
iaere
Address(if different from location)
CitylTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping pat VC 2. Quantity Pumped: /00 Qad
G Mons
3. Component: ❑ Cess ool(s) ❑ Septic Tank 1 ❑ Tight Tank A--Qrease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes k No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
kiT-avu C �sg-
Observations are d er's opinion based on what he sees at time of pumping on the date above.
6. Quatern umped y:
11
me Vehicle License Number
J&S Development Corp. d/b/a
Stewart's Septic 58 So. Kimball St., Bradford,MA
7. Location where contents were disposed:
Ste 's lobal Env'io 20 So. Mill St., Bradford, M g018 5
Same
Signature uler Date
Same
Signature of Receiving Facility(or attach facility receipt) Date
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