HomeMy WebLinkAboutBake N Joy-Sludge Tank-4000 Gal - Septic Pumping Slip - 351 WILLOW STREET 9/13/2024 Commonwealth of Massachusetts
- w 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:
� Le-
Name
SAME
Address(if different from location)
..._.. _._. _ _....._ _.-._._._..
City/Town State Zip Code
--
Telephone Number
--- --
B. Pumping Record
1. Date Of Pumping -� -p_ __ 2. Quantity Pumped;
Date Gallons
3. Component:
❑ Tight Tank ❑ Grease Trap
Cesspool(s)
Septic Tank
Other(describe): �.
4. Effluent Tee Filter present? ❑ Yes . O If yes, was it cleaned? ❑ Yes ❑ No
5. Observed c ndition of component pumped:
All of this estimated
information is nbn"-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. System u ed By:stem m
Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stew Recei ing Facility, 20 S ill St., Bradford, MA 01835
_ - �
Si nature of Hauler
above
_..._ ___ __... . — -_ _-.-_.._._.-._.
g Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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