HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 351 WILLOW STREET 4/18/2025 1`o�rn of forth Andover
Commonwealth of Massachusetts
City/Town of No. Andover
wry System Pumping Record MAY 2025
Form 4
He `th epart e
DEP has provided this form for use by local Boards of Health. Other forms may be used;buNe
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 _ 351 Willow Street
key to move your Address
cursor-do not No. Andover MA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
F� Bake 'N' Joy-
Name
SAME
Address(if different from location)
CitylTown State Zip Code
Telephone Number
1. Date of Pumping Date 2. Quantity Pumped; 11
allons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): Sludge
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed V!i,
tion of component pumped:
SLUDGE All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
& Syst Pumped By: ry
Names Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewart's Receiving.F cility, 20 So-,Mill St., Bradford, MA 01835
See above -
Signature of Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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