HomeMy WebLinkAboutButcher Boy-Grease Trap - Septic Pumping Slip - 1077 OSGOOD STREET 2/5/2025 Commonwealth of Massachusetts Town
of NOrthAndover
City/Town of No Andover
MAR 4
System Pumping Record �025
Form 4
'b t th
DEP has provided this form for use by local Boards of Health. Other fol t e
"47 C 4
information must be substantially the same as that provided here. Before using hisl* your
local Board of Health to determine the form they use, The System Pumping Record must be s!Mlied 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
use the return State Zip Code--""""'-----
key.
CitylTown 2. System Owner:
Name
Address(if different from location)
No Andover MA
City/Town State Zip Code
B. Pumping Record
1. Date of Pumping *Date0-5-72. Quantity Pumped: 'G;I�Lns--
3. Component: .j Cesspool(s) ❑ Septic Tank ❑ Tight Tank Grease Trap
E] Other(describe):
4. Effluent Tee Filter present? El Yes�j No If yes,was it cleaned? Yes No
5. Observed condition of component pumpe
6. Sys m Pu ped Nam",:
Vehicle License Number
Stewart's Septic 58 So Kimba_�ISt. Br@dfqLdIVIA
Company
7. Location where contents were disposed:
'-S Signature
Signature of Receiving-Facility-(or attach--f,a,-c,ili-ty-re-c-ei,p--t-)-- b-a-t-e' —---------
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