HomeMy WebLinkAboutDominic's Diner Grease Trap - Septic Pumping Slip - 492 SUTTON STREET 4/18/2025 Town of Noah Andover
Commonwealth of Massachusetts APR 2 2:12025
City/Town of Ltgf:kV\ A(\ .OQp C
System Pumping Record Healtih Department
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 15.361.
A. Facility Information
Important:When
Ming out forms 1. System Wcation:
on computer,
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key- State Zip Code
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VS40 jj 2. System Owner
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Nam
Address Of different from location)
Cityrrown State Ztp Code
Telephone Number
S. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: El Cesspooks) f-1 Septic Tank 0 Tight Tank Grease Trap
0 Other(describe):
4. Effluent Tee Filter present? [3 Yes No If yes,was it cleaned? 0 Yes ❑ No
S. Observed condition of component pumped:
6. System Pumped By:
.N .......
. .11"e . Vehicle Lioeme Number .
—rm 10 ow
company
7. Loca9e n where contents were disposed:
c'
XAg&We Date
Signature of Receiving Facility(of attach facility receipt) Date
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