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HomeMy WebLinkAboutBake N Joy Sludge Tank 2500 Gal - Septic Pumping Slip - 351 WILLOW STREET 12/18/2024 °w Commonwealth of Massachusetts Town Of "D d Andover y City/Town of No. Andover JAN System Pumping Record 7 225 Form 4 . DEP has provided this farm for use by local Boards of Health. Other farms may be 9P, # ent 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, G°V!0/o("i 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 t 2. System Owner: Name SAME Address(if different from location) _ _.._.. ....... _------- --- _ _ City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping - 4 ( m 2. Quantity Pumped: Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septiq T nk ❑ Tight Tank ❑ Grease Trap Other(describe): -.c! ? Gs/ , 4. Effluent Tee Filter present? ❑ Yes o 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#Ime of pumping, Not responsible beyond the date above. 6. System Pumped By Name Vehicle Lice11 nse Number J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Stewart;'# Receiving Facility, 20 So. Mill St., Bradford, MA 01835 "- .� ... �,, C . _._.._ ........... ..... .._.___........ .......... ._... ... _.... ,_,_ _.._. Signature of Hauler Date See above Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record«Page 1 of 1