HomeMy WebLinkAboutBake N Joy Sludge Tank 4000 Gal - Septic Pumping Slip - 351 WILLOW STREET 12/28/2024 ndOver
Commonwealth of Massachusetts
City/Town of No. Andover
J 2025
µ. rR stem Pumping Record
Form 4 Ip;�'I
a s.W , nt
DEP has provided this form for use by local Boards of Health. Other forms 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,
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
Qb
2. System Owner: pp,
Name
n SAME
.. .. . ...
Address(if different from location)
City/Tawn State Zip Code
Telephone Number
..,m�,�y,Yma-wrvrvmn:,+*:Mwro:.h ��.,,.....�.«, .�,�..,a................................:.....,....,..,...n_,.,,.._,_„_,....,._.,.,...,,,..�,�,:..-...,.,.,.........,....,..,�.......,,_...,,..,.......,.,..�s...-,-...._.u...,,-_..._._........_........�.._.�_. .w,—.,.._......-...,.--.. —.......r . Prurlr 'oling Record
1. Date of Pumping Date
2. Quantity Pumped: a
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
(❑ Other(describe): ,.„
4. Effluent Tee Filter present? ❑ Yes a No If yes, was it cleaned? ❑ Yes ❑ No
^;.
5, Observed coditian of component pumped:
�
- All of this estimated
information is non-binding, valid only_at,the.time of pumping. Nat responsible beyond the date above.
6. System Pumped By
<Ne Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stews Receivin �acil So Mill St., Bradford, MA 01835
�,.
See above
Signature of _
Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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