HomeMy WebLinkAboutBake N Joy - Grease Trap 4000 - 11/8/2024 - Septic Pumping Slip - 351 WILLOW STREET 11/8/2024 Commonwealth of Massachusetts
o m. :((� City/Town of No. Andover
�� �+ 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 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:
k Qw Bake 'N' Joy
Name
SAME
Address of different from location)
Gity/Town State Zip Cade
Telephone Number
..........._........_____.._.._..----------- ..._
B. Pumping Record
1. Date of Pumping Date ............ .........._____ 2. Quantity Pumped: d710 _-.._._._._.
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
Info1111-111rmation Is non-binding, valid only at the time of pumping,.-Not responsible, beyond the date above.
6. System Pumped By:
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewart's MA Receiving Facility, 20 So. Mill St., Bradford, 01835
See
Signature of auieL-xr Date
--__-above
See above
Signature of Receiving Facility(or attach facility receipt) Date
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