HomeMy WebLinkAboutSludge Tank Pumping Slip - Bake N Joy - 11/18/2024 - Septic Pumping Slip - 351 WILLOW STREET 11/18/2024 Commonwealth of Massachusetts
p City/Town of No Andover
- System Pumping Record
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, ❑ 6 c -I i
use only the tab ®/ .....�
key to move your Addr s
cursor-do not
use the return -- --- — .......................__ .. __. ❑_._. _._.. _._.�.
key. City/Town State Zip Code
2. System Owner:
t� ❑1"5 V c a ❑GJ
Name 1
wr _
Address(if different from location)
No Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:Date Gallo❑ —
3. Component: [_,] Cesspool(s) ❑ Septic Tank ( .) Tight Tank L] Grease Trap
ap k
[_ Other(describe):
4. Effluent Tee Filter present? (._..._] Yes❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed co dition of component pumped:
961
y m Pumped By:
6. System Cam,,.. ❑e°,��� '�❑ "��
Oame Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
Zd,MASignature r date
Signature of Receiving Facility(or attach-fa 6i—lit—y receipt) Date
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