HomeMy WebLinkAboutGrease Trap-Tavern - Septic Pumping Slip - 18 HIGH STREET 6/4/2025 Commonwealth of Massachusetts North 'er
w City/Town of No.Andover
System Pumping Record 42025
fForm 4OeP
DEP has provided this form for use by local Boards of Health. Other forms may be used
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 --
key to move your Address
cursor-do note ,
use the return ... _. ._. __.__ -------------...._..._......_____-_
key. City/Town State Zip Code
2. System Owner:
le
Address(if different from location)
No.Andover' MA
City/Town State Zip Code
Telephone Nuriber -----_____--
B. Pumping Record
1. Date of Pumping o t- — 2. Quantity Pumped: G_Plons
3. Component: Cesspool(s) Septic Tank ] Tight Tank Grease Trap
1 Other(describe): - ____ _..,......_
4. Effluent Tee Filter, present? I Yes i No If yes, was it cleaned? ] Yes .� No
5. Observed condition of component pumped.
6. S mPmed
Na Vehicle License Number
Stewart's Septic 58 So Kimball St Bradford,MA.
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
Signature of Hauler fate
Signature of Receiving Facility(or attach facility receipt) date
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