HomeMy WebLinkAboutBake N Joy Grease Trap Batter 2500 Gal - Septic Pumping Slip - 351 WILLOW STREET 12/6/2024 Commonwealth of Massachusetts
C( City/Town of No. Andover p over
System Pumping Record
Form 4 JAN 7 2025
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. N n ith your
local Board of Health to determine the form they use. The System fitted 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. ___ .. _ _...
key. City/Town State Zip Code
"IOU2. System Owner:
JoBake'N`Joy _
Name
{ SAME
Address(if different from location)
City/Town State Zip Code
Telephone Number
_ B. Pumping Record -
1. Date of Pumping bat 2. Quantity Pumped: �Gllons
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 0 No
5. Observed condition of component pumped:
Batter/Sludge All of this estimated
information is non-binding, valid only at the time of pure ing. Not responsible beyond the date above.
6. System P d By:
_
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewart's Receivi _g Facility, 20 So. Mill St, Bradford, MA 01835
11
See above
__ _ . _
signature of Hauler - Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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