HomeMy WebLinkAboutBake N Joy-Sludge Tank-4000 Gal - Septic Pumping Slip - 351 WILLOW STREET 9/10/2025 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 _ ....._._ . _..._. _ .--_--
key to move your Address
cursor-do not No. Andover MA 01985
use the return ---- ---- - -- -
key. City/Town State Zip Code
2. System Owner:
Name
SAME
Address(if different from location)
State— --- - ----- Zip C-_.o..de - ---- -
C�ty/Town
Telephone Number
B. Pumping Record
Date Gallons
1. Date of Pumping _ —=-- � ._ _....__ 2. Quantity Pumped:
s
3. Compon Els o Cesol(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 conditi of component pumped:
All of this estimated
information is non-binding, valid only at the time of pumpin�c. Nat responsible beyond the date above.
6. System Pumped By:
Name Vehicle Li ense Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
/Stew ec 'ving Facility, 20 So. Mill St., Bradford, MA 01835 _
.......
See above
of Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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