HomeMy WebLinkAboutTavern on High Grease Trap - Septic Pumping Slip - 18 HIGH STREET 5/12/2026 Commonwealth of Massachusetts Town Of No E'i Andover
p City/Town of No. Andover
w° System Pumping Record JUN f 2026
Form 4
DEP has provided this form for use by local Boards of Health. Other forms ❑'l e L; ent
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
fining out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
- -- --
cursor-do not No. Andover MA 01845
use the return ....... _ _ ...... ....._.. ...._. --
key, City/Town State Zip Code
VQ 2. System Owner: ........ -K
❑/
Same ' � ❑ f ' ❑ ,
Name
�etum
Address(if different from location)
-- __ --- — - ---- ---- --- __. _ .....
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping a ` - 2. Quantity Pumped:
Ilons
3. Component: ❑ Ces pool( ) ❑ Septic Tank ❑ Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ( ,No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
All of this estimated
information Is no - finding, valid only at the time of pumping_ Not responsible beyond the date above.
--- -- ....... .......
6. System edgy:
... ._._. -
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service, 58 So. Kimball St., Bradford, MA 01835
7. Location where contents were disposed:
Stewart's Receiving Facility, 20 So. Mill St., Bradford, MA 01835
_ ... _
See above
— --
Signature of Hauler Date
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Signature of Receiving Facility(or attach facility receipt) Date
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