HomeMy WebLinkAboutBake N Joy Sludge Tank 4500 Gal - Septic Pumping Slip - 351 WILLOW STREET 12/19/2024 Commonwealth of Massachusetts J"�T�)rth Andover
City/Town of No Andover
SAN 7 2025 ystem Pumping Record J '
Form 4
DEP has provided this form for use by local Boards of Health. Other for 4s';."'b'6 Q6
information must be substantially the same as that provided here. Before using this fon�cleftPA3ur
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 CIVIR 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
use the return
key, City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
No Andover MA
City/Town State Zip Code
B. Pumping Record
44 4-':)()
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: Cesspool(s) Septic Tank Tight Tank ❑ Grease Trap
[?-Other(describe):
4. Effluent Tee Filter present? ['-] Yes No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
& System Pu d By:
Nam TJ FOie—ucense Number
Stewart's eptic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 SoMill St.,Bradford,IVIA
Signature of Hauler Date
S"rgnature Fic—iiity(®raftta-Gh facility receipt) Date
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