HomeMy WebLinkAboutBake N Joy-Sludge Tank-5000 Gal - Septic Pumping Slip - 351 WILLOW STREET 9/20/2024 Commonwealth of Massachusetts
City/Town of No. Andover
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,
use only the tab / V
6. ....
key to move your Address
cursor-do not No. Andover MA 01845
use the return _ _ ____
key. City/Town State Zip Code
VQ 2. System Owner:
Name
SAME
_. __._ ._ ._.. . _ _ --._ .. ..._.._.... ._ . .....
Address(if different from location)
City/Town _ State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date . 2. Quantity Pumped: Gallons
3. Component: e Cesspool( ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe): _. _
4. Effluent Tee Filter present? ❑ Yes k No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed�ondition of component pumped:
Its All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
System Pumped By✓
6. yst
�Vehicle
License Number
J&S Development Corp. d/b/a Stewart°s Septic
Service
7. Location where contents were disposed:
Stewa Receiving Facility, 0 So. Mill St., Bradford, MA 01835
See above
Signature of Hauler Gate
SAME
Signature of Receiving Facility(or attach facility receipt) Gate
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