HomeMy WebLinkAboutBake N Joy-Grease Trap Batter-3000 Gal - Septic Pumping Slip - 351 WILLOW STREET 11/27/2024 Commonwealth of Massachusetts
City/Town of No. Andover
I - System Pumping Record
Form 4
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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 _ _ ---._ 351 Willow Street
key to move your Address
cursor-do not No. Andover MA 01845
use the return _
key. CitylTown State Zip Cade 111 2. System Owner:
r� Bake 'N' Jqy
Name _.
SAME
Address(if different from location)
City/Town State Zip Code
__ .._ -. ...._..
Telephone Number
B. Pumping record
1. Date of Pumping -Date11,11, 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap
Other(describe): Batter
4. Effluent Tee Filter present? ❑ Yes ® No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
".
Batter/Sludge C All of this estimated
information is non-binding,, valid only at the time of pumping. Not responsible beyond the date above.
y 6. System Pumped B
Name Vehicle Lice
nse Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewa Recelvin Facilit 20 So. Mill St., Bradford, MA 01835
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Uz-
See above ,i r
Signature of Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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