HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 1077 OSGOOD STREET 4/2/2024 Commonwealth of Massachusetts Torn of ® h Ana4Ver
W City/Town of No Andover
a W° System Pumping Record APR p 2 2024
Form 4
rt.
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, y")C,
use only the tab 6—old S7— /D 7-7
(�"'
key to move your Addres
cursor-do not /��l'/
use the return City/Town State Zip Code
key.
2. System Owner:
Name
Address(if different from location)
No Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
—;/i 2 �
1. Date of Pumping Dat 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank rease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
UU'c7�
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
c 4Dtuler
Signature of Receiving Facility(or attach facility receipt) Date
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