HomeMy WebLinkAboutButcher Boy Grease Trap - Septic Pumping Slip - 1077 OSGOOD STREET 8/14/2026 �c�wn � ®r� Andover
Commonwealth of Massachusetts
i) LL_ =r� City/Town of No.An over 2026
a Systems Pumping Record
Form 4
Health e a
r$men
DEP has provided thi form for use by local Boards of Health. Other farms may used, bu the
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, ( J
use only the tab
key to move your Address
cursor-do not
use the return 11 _.
cityCl awn State Zip Code
key.
2. System Owner:
rye �
reran M....
_. . .. _ __. ...
Add__ressu_ (if different from location)
No.Andover MA
city/Town State Zip 111 Cade
Telephone Nur,iber
B. Pumping Record
1. Date of Pumping oath -._ _- ' __.__. 2. Quantity Pumped; a ._... . __.
3. Component: Cesspool(s) Septic Tank Tight Tank Grease Trap
Other (describe):
4. Effluent Tee Filter present? ( Yes �_v No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
6. System Pumped B U
Name vehicle License Number
Stewart s Septic ]8 So Kimball St Bradford,MA
company,
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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