HomeMy WebLinkAboutBake N Joy-Sludge Tank-2500 Gal - Septic Pumping Slip - 351 WILLOW STREET 10/1/2024 j
a Commonwealth of Massachusetts
W� City/Town of No. Andover
a System Pumping Record
.._ Form 4
DEP has provided this farm 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 farm, 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 farms 1. System Location:
on the computer,
use only the tab _�✓l'l_ .w w ... .w...
key to move your Address
cursor-do not No, Andover MA 01845
use the return -- -
key. City/Town State Zip Code
� 2. System Owner. , /
c
Name
"
n SAME
- ---
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of PumpingU 'rc ` �y 2. Quantity Pumped: 00
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:
! All of this estimated
information is non-binding, valid only at th e 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 Facility, 20 So. MITI St., Bradford, MA 01835
,. See above
of Hauler Date
SAME
Signature of Receiving Facility(or attach facility receipt) Date
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