HomeMy WebLinkAboutPita Thyme Grease Trap - Septic Pumping Slip - 550 TURNPIKE STREET 4/16/2025 Town of NoOhAndover
C�rrrrrri�onwealth of Massachusetts APR 212025
City/Town of L , J�r qq oVe r
System Pumping Record Health Department
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
lnformadon 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 16.361.
A. Facility information
Important:V11 w
filling out kumms 1. System Location:
On the use only tl b'key to move your Add
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may state Zip Code
2. System Owner:
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Address pfr>��rs�"rorni bt�k'af}
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
G' ns
3. Component. ❑ Cesspool($) ❑ Septic Tank ❑ Tight Tank Crease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
6. Observed condition of comment pumped:
6. System Pumped By:
Nam Vehicle License Number
jr 11mpanry e �
7. Location where contents were disposed:
e safer Date
signature of Receiving Fartifity(or attars faclnty Date � � "
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