HomeMy WebLinkAboutBake N Joy Grease Trap 4500 - 11/8/24 - Septic Pumping Slip - 351 WILLOW STREET 11/8/2024 Commonwealth of Massachusetts
- � City/Town of No. Andover
- w 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,
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:
tab
Bake'N' Joy.._..... .
Name
awm 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:
Batter/Sludge All of this estimated
Information is non-binding, valid-only at the time of pumping. Not responsible_beyond the date above.
6. S&s3u
m p Y� ..
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Ste Receiving F cility, 20 So. Mill St., Bradford, MA 01835
�" - -- - - See above
Signature of Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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