HomeMy WebLinkAboutBake N Joy Sludge Tank 5000 Gal - Septic Pumping Slip - 351 WILLOW STREET 12/13/2024 Commonwealth of Massachusetts Town OfNO*Andover
cs) � City/Town of No. Andover JAN7 2025
Lr, System Pumping Record
! Farm 4Department
DEP has provided this form for use by local Boards of Health. Other farms 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, `r"i r-
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
P
�� 2. System Owner: ( .�
tsb
Flame
�t SAME
Address(if different from location)
City/Town State Zip Code
Telephone Number
.. ...... aa..
B. Pumping Record we�. _
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 allo If yes, was it cleaned? ❑ Yes ❑ No
5. Tberved codition of component pumped:
All of this estimated
information is non-binding, valid only at the time ofpumpmg. Not responsible beyond the date above.
6. System Pumped By.�_,,_. "
-
j. _
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
c
tewaeC@IVing a J 20 Sp Mill St., Bradford, MA 01835
.. 43See above -'
I y,_
Sig ature of Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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