HomeMy WebLinkAboutBake N Joy Sludge Tank 4500 Gal - Septic Pumping Slip - 351 WILLOW STREET 12/6/2024 Commonwealth of Massachusetts
rn = 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,
use only the tab d
_..... .............. ------------.
key to move your Address
cursor-do not No. Andover MA 01845
use the return _ - -. _
key.
City/Town State Zip Code
2. System Owner:
Name _
SAME
Address(if different from location)
Ei
Cit !Town tb* Zip Ca 11 de
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):
4. Effluent Tee Filter present? ❑ Yes Ej,No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
All of this estimated
information is non-binding, valid onl"y at the time of pumping. Not responsible beyond the date above.
6. System Pumped By
eame.
Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stew Re iving Facility, 20 So. Mill St., Bradford, MA 01835
L-. .. J.... See above
Signature of Hauler Date
_ See above
Signature of Receiving Facility(or attach facility receipt) Date
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