HomeMy WebLinkAboutBake N Joy-Grease Trap-4000 Gal - Septic Pumping Slip - 351 WILLOW STREET 9/24/2024 Commonwealth of Massachusetts
City/Town of No. Andover
System Pumping Record
w Form 4
DEP has provided this form for use by local Boards of Health. Other farms 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 ti _ ..u."
key to move your Address
cursor-do not No. Andover MA 01985
use the return - - -- _
key. City/Town State Zip Code
r� 2. System Owner; 310,
Name ---
SAME
_.._..._
Address(if different from location)
_ -------.... __ - .. -..... ---
City/Town State Zip Code
Telephone Number
B. Pumping Record
Date Ins
1. Date of Pumping - 2. Quantity Pumped:
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 No
5. Observed con It
of nt pumped:
,j7
All of this estimated
infarmati is on-binding, valid only at the time of ........ . __. eyond the date above.
& System P ed B
P
Name e_
�M�e7r
. ,. _ ....
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewa ,RingFacility, 20 So. Mill St., Bradford, MA 01835
_ See above _-
_ . ...
�,.......��....�...._. Date
Signature of Haul
See above
Signature of Receiving Facility(or attach facility receipt) Date
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