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HomeMy WebLinkAboutBake N Joy-Sludge Tank-5000 Gal. - Septic Pumping Slip - 351 WILLOW STREET 9/27/2024 Commonwealth of Massachusetts W City/Town of No. Andover System Pumping Record vn; .y 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 CIVIR 15,351. A. Facility Information Important:When filling out forms 1 System Location: on the computer, (ter, use only the tab ....... _._.. .._._.._ key to move your Address cursor-do not No. Andover MA 01985 use the return key. City/Town State Zip Code 2. Sys tem Owner: � Y Name 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 ❑ Grease Trap ET"C7ther(describe); -- 4. Effluent Tee Filter present? ❑ Yes (E No If yes, was it cleaned? ❑ Yes ❑ No b dition component pumped:f 5. Observled�con. � pp All of this estimated Information I's non-binding, valld.only at the time of pumping. Not responsible beyond the date above. 6. System Pumped By,, Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Stewart, /wing Facility, 20 o MIII t., Bradford,' r° r J M See above r '' (°'Signature of Hauler Date See above Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record.Page 1 of 1