HomeMy WebLinkAboutGrease Trap - Tavern On High - Septic Pumping Slip - 18 HIGH STREET 2/2/2026 Commonweal h of Massachusetts t, Andover
M City/Town of
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w° System Pumping Record 22
Form 4
M q
Y.. i DEP has provided this form for use by local Boards of Health. Other f
information must be substantially the same as that provided here. Before using this f rm,"dggh 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 j--
key to move your Address
cursor-do not `
use the return _
key. City/Town State Zip Code
r�
2. System Owner: � ..
1.4
Name
&X 11t,111.
—......_ __.._.. _ -- . ._._......-..—._ _.. . . . -
-......---.. .. ... ........ _.__... —_-.._.�_...
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping — 2. Quantity Pumped: _._ .._..__ .-.-----.._......._
Gallons
3. Component: f Cesspool(s) Septic Tank j� Tight Tank Grease Tra
Other(describe): -_._.. _ - _._ - ---
4. Effluent Tee Filter Yes resent? to p � i . If yes, was it cleaned? Yes _] Na
5. Observed c ndltion of com onent pumped:
6. Syste umpe
Name 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 Efate
.. _ ... -
Signature_ _ of Receiving- __--
Facility-- ---(o—r attach facility receipt) Date
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