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HomeMy WebLinkAboutBake N Joy - Grease Trap 1500 - 11/5/24 - Septic Pumping Slip - 351 WILLOW STREET 11/5/2024 Commonwealth of Massachusetts 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 tilling 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'N' Jay_...._.. Name SAME Address(if different from location) .- _-.----_.- City/Town State Zip Code ——-- -- ------ - ......... Telephone Number B. Pumping Record - - 1. Date of Pumping 2. Quantity Pumped: Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): -------------- -- — Batter 4. Effluent Tee Filter present? ❑ Yes ® No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: //7 Batter/Sludge %C Y..m...,..M... _ All of this estimated information is non-binding, valid only at_the time of pumping. Not responsible beyond the date above. 6. Syste Pumped B& .. Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: y 20 SSo. Mill St., Bradford, MA 01835 Ste eceivin Facility, , See above..-.x - --------- - Signature of Hauler Date See above -- -_ _ - - . . - — .__ - --- Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record-Page 1 of 1