HomeMy WebLinkAboutBake N Joy - Sludge Tank - 11/4/24 - Septic Pumping Slip - 351 WILLOW STREET 11/4/2024 Commonwealth m� A8 �
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System Pumping
Record
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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 |ooe| Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310CN1R 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, ~
use only the tab
key to move your Address
rumn, do not
use the return Code
key. City/Town State Zip
_ SystemOwner:
Itz L7�z,,,
Name
Address(if different from location)
No Andover M8
City/Town State Zip Code
Telephone Number
B. Pumping Record — - — — —
1. Date ofPumping 2Date/ � (2uentityPumped� Gallons
3. �om nt� �� Cesspool(s) E] Septic Tank [l Tight Tank [l Grease Trap
�� Other(deaoribe): --
4. Effluent Tee Filter present? Yes Oj� »uo |f yes, was itcleaned? E] Yes E] No
5. Observed condition of component pumped:
S. S t P mped Q
Name Vehicle License Number
St wmd'm Septic 58 So Kimball St Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mll S B dfo d W1A
, / J
Signature of Hauler- Date
SignatureofReceiving Facility(or attach facility receipt) Date
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