HomeMy WebLinkAboutBake N Joy-Sludge Tank-5000 Gal - Septic Pumping Slip - 351 WILLOW STREET 9/13/2024 Commonwealth of Massachusetts
N 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 OMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
r
key to move your Address -
cursor-do not No, Andover MA 01985
use the return - -- - _. --- - ----- -- - - ---- ---- --- ---
key. City/Town State Zip Code
2. System Owner:
r� r
Name
arum SAME
Address(if different from location)
_ ....... ------_... ------
City/Town State Zip Code
— -----.---___._-...---__.._..._..._.__..__..___....---._.___...............
Telephone Number
B. Pumping Record
1. Date of Pumping f -� --__ 2. Quantity Pumped:
---
Date Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped: ,�
�� e"' All of this estimated
Information is non-binding, valid 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's Receiving-,Fac�, 20 So. MITI St., Bradford, MA 01835
- _ .
" -f Hauler
sr � u o See above
I ig ler Date
" See above
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc-11112 System Pumping Record•Page 1 of 1