HomeMy WebLinkAboutBake N Joy Sludge Tank 4000 Gal - Septic Pumping Slip - 351 WILLOW STREET 12/20/2024 Tol t7 of AndoVer
Commonwealth of Massachusetts !
City/Town of No Andover
JN
System Pumping Record A 72025
Form 4
DEP has provided this form for use by local Boards of Health. Other forms'rh
information must be substantially the same as that provided here. Before using this�fform,uwith 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 J
key to move your Address
cursor-do not
use the return State Zip Code
key. -6t—yFTown
2. System Owner:
Name
Address(if different from location)
No Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
ell 4�
1, Date of PumpingDateQuantity Pumped: Gallons
3, Component: Cesspool(s) I Grease Trap
Septic Tank Tight Tank
C
O"Other(describe):
4. Effluent Tee Filter Present? El Yes [I No If yes, was it cleaned? Yes E] No
5. Observed condition of component pumped:
6. Syste umpe By:
2Narrve Tehicie License Number
Ste rt's.S ic 58 So Kimball St. , qr�!qfordMA
_
Company
7. Location where contents were disposed:
20 SoMill St.,Bradford,MA
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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