HomeMy WebLinkAboutBake N Joy Sludge Tank 3000 Gal. - Septic Pumping Slip - 351 WILLOW STREET 12/13/2024 - � North Andover
Commonwealth of Massachusetts
City/Town of No. Andover
wµ _ PAN Y
System Pumping Record ZOZS
/ Form 4
DEP has provided this form for use by local Boards of Health. Other forms rn� t
information must be substantially the same as that provided here. Before using this form, check wititt our
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, vv
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
� 2. System Owner:
Name
rersn SAM E
Address(if different from location)
- ---....---
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping G
- 2. Quantity Pumped: _allo__ ..-... - ._.----. ......
Date ns
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
[der(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed co dition of component pumped:
-y* All of this estimated
Information is non-binding, valid only at the time of pumping Not responsible beyond the date above.
System Pu
mped By
..µ ° - --
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
ty, 20 So Mill St., Bradford, MA 01835
ZSte �eiving Facility,
2 _
r .mom
c � '` See above / -
f Haurer Date
See above
Signature of Receiving Facility(or attach facility reoeipt) Date
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