HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 733 TURNPIKE STREET 2/6/2023 IL
Commonwealth of Massachusetts REGEIVE0
w City/Town of
System Pumping Record
Form 4
or NORTH ANDOVER
i 6EPARTMENT
DEP has provided this form for use by local Boards of Health. Otl rorms 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, ��-�� Ste[
use only the tabs r
key to move your Address
cursor-do not f- MA
use the return _
key. City/Town State Zip Code
r� 2. System Owner:
(i �
Name �l) �I 1 t -- --
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping _J Date J 2. Quantity Pumped. Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes dNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
y� 1 L? IA1_j
—
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill St., Bradford, MA
- � - )S-cU
ature of Hauler Date
Same day
Signature of Receiving Facility(or attach facility receipt) Date
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