HomeMy WebLinkAboutBake N Joy-Grease Trap-3500 Gal. - Septic Pumping Slip - 351 WILLOW STREET 9/20/2024 ❑ Commonwealth of Massachusetts
w City/Town of No. Andover
M System Pumping Record
Form 4
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, p
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
r� 2. System Owner: r
Name
�r SAME
------ --- ___-... _ ----- -- -- _
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ----- -._.__-- 2. Quantity Pumped: --- - -- ----
Date Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank rease Trap
❑ Other(describe): --
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes 2'No
5. Observed condition of compone t;pumped:
All of this estimated
information is no i ing,_valid only at the tlme_of pumping. Not responsible beyond the date above.
._.._.._ - --
6. System P mped By- -
� ...
...................._-
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewartg eia�ft.-Fac 4ty:20 So. Mill St., Bradford, MA 01835
See above
-Stgrr'ature of Ha _ Date
SAME
Signature of Receiving Facility(or attach facility receipt) Date
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