HomeMy WebLinkAboutButcher Boy Grease Trap - Septic Pumping Slip - 1077 OSGOOD STREET 12/11/2025 'C\ Commonwealth of Massachusetts TOM of North Andover
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System Pumping Record JACK ,- 5 2qo�p
Form 4
DEP has provided this form for use by local Boards of Health. Ot ST n e
information must be substantially the same as that provided here. Before using this form, c k 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 CM R 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 MA
use the retu
key. rn City/Town State Zip Code
VQ 2. System Owner:
1h -Vr-,Vw--r
Ide Name
reesn
Address(if different from location)
City/7own State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dat 2, Quantity Pumped: Gallons
1 Component: F7 Cess/poo�(s) ❑ Septic Tank F7 Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? F7 Yes F7 No If yes, was it cleaned? F7 Yes 7 No
5. Observed condition of component pumped:
bo
C-) All of this estimated
information is.non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. System Pumped By:
Name Vehicle License Number
J&S Development Corp. d1b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewart's global Environmental, LLC
20 So. Mill St., Bradford, MA 01835
Signature See above
o�Hau
ler Date
See above
Signature of Receiving FacHity(or attach facility receipt) Date
t5form4.doc- 11/12
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