HomeMy WebLinkAboutBake N Joy Sludge Tank 5000 Gal - Septic Pumping Slip - 351 WILLOW STREET 12/11/2024 Commonwealth of Massachusetts TOM O'NoMh Andover
�1 City/Town of No. Andover JAN 7 2025
System Pumping Record
� Farm 4r)ONIrtment
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 _. .__....... _... .. ..._._...._.._._.....----
key to move your Address
cursor-do not No. Andover MA 01845
use the return
key. City/Town State Zip Code
Y2. System Owner: 1.9 ( r
Name
9 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
/Lf ,
Other(describe): L _ • . 't l e
4. Effluent Tee Filter present? ❑ Yes Et--No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
- All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. System Pumped By
Na Vehicle License
ense Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
_war Receivin acllit , 20 So Mill t., Bradford, MA 01835 to y
See above ffi
- ...-...__... _ ..._ _ / _...___ ----...
Signature of Hauler �" 9;7ate
See above
Signature of Receiving Facility(or attach facility receipt) Date
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