HomeMy WebLinkAboutBake N Joy Pumping Slip - Sludge Tank - 10-15-24 - Septic Pumping Slip - 351 WILLOW STREET 10/15/2025 Commonwealth of Massachusetts
a City/Town of No. Andover
System Pumping Record
owe Form 4
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,
use only the tab _ _351 Willow Street
key to move your Address
- _ _... _ .
cursor-do not No. Andover MA 01845
use the return _. _
key. City/Town State Zip Code
° 2. System Owner:
-Bake Joy
Name. . _
Q SAME
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date ... 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank E Grease Trap
Other(describe):
,.... M��,,. - Batter
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed cond' ' n of component pumped:
P ..... Batter/Sludge All of this estimated
Information is non-binding valid only at the time of pumping Not responsible beyond the date above.
& System um ed y
Name Vehicle L icens NuTn45�er
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
❑ing Fac'i 20 So. Mill St., Bradford, MA 01835
See above . , .,
' _�..�
Signature of Hauler Date
See above
....w _._.... .
Signature of Receiving Facility(or attach facility receipt) Date
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