HomeMy WebLinkAboutBake N Joy Sludge Tank 2500 Gal - Septic Pumping Slip - 351 WILLOW STREET 12/16/2024 Commonwealth of Massachusetts Tc nof 1VOrMAndoVer
M ❑--6, City/Town of No. Andover JAB 7 2
025
- f System Pumping Record
Form 4fte b�: ► Depa
� q
DEP has provided this form for use by local Boards of Health. Other forms may be used, 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 -
_ _ ..1 .. .._._ �_... .
key to move your Address
cursor-do not No. Andover MA 01845
use the return _.__...... .
key. City/Town State Zip Code
2. System Owner:
V1 6114
Name
gin SAME
..._..._..._.__. ._...... .. _ ................._ ,._,, .__.._._.._...
Address(if different from location)
City/Town State Zip Code
-_... ...
Telephone Number
8�. Pumping R�cc�rd .�
1. Date of Pumping — 2. Quantity Pumped: . ..___. _ .. ..
Date Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
p
Other(describe): ! "7 ._.
4. Effluent Tee Filter present? ❑ Yes [ - No If yes, was it cleaned? ❑ Yes ❑ No
5. Obser
ved condii'on 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
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Ste warts Receiving Faciliit 20 So. Mill St,, Bradford, MA 01835
" ,, r 1 •. __._. See above...
Signature of Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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