HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 10/25/2016 RECEIVED
Commonwealth of' Massachusetts
City/Town of No Andover NOV 14 ?016
System Pumping Record TOWN U�NUR I H ANDOVER
HEALTH DE FART MENT
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but 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,
use only the tab
key to move your Addre
cursor-do not
use the return ��
key. City(Town State Zip Code
2. System Owner:
I\j
Name
Address-(if-different from location) ----------
dty/Town State Zip Code --------
'Teiepkone----Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
EKOther (describe): Q,
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observe j c9ndition of component pumped:
6. System Pumped By:
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7, Location where contents were disposed:
20 mill st-bradford m
ign ure aut) Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc-11/12 System Pumping Record•Page 1 of 1
Commonwealth of'Massachusetts RECEIVED
City/Town of No Andover
NOV 14 Z016
System Pumping Record
'rOWN OF NOR I i-1 ANDOVER
Fo'rm 4 HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but 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 CM R 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab I (k)� 1-I uk)------------- M
key to move your Add
cursor-do not
use the return
key. City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) [I Septic Tank ❑ Tight Tank [Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed cc ition of component pumped:
----------
6. System Pumped By:
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20-sp mill st braqforql"frWq—"-\
t,'�drrsture ck,filAuler L— Date
Signature of Receiving Facility-Kr attach facility receipt) 'date
t5form4.doc-11/12 System Pumping Record-Page 1 of I
Commonwealth of' Massachusetts
City/Town of No Andover RECEIVED
System Pumping Record Nov 14 Z(jjr�
Form 4
TOWN OF-114UWHANDOVER
DEP has provided this form for use by local Boards of Health. Other forms m B&IfN6
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 not K� ,
use the return
key. City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
----------I--------------------- ..........
CityfTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) [:1 Septic Tank ❑ Tight Tank ❑ Grease Trap
N"16'ther(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
---——---------
6. System Pumped By:
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
40 so rqjtI-- ratffprd ma
Sig ature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc-11/12 System Pumping Record-Page 1 of 1
Commonwealth of' Massachusetts
City/Town of No Andover
REcE
System Pumping Record IVED
Form 4 NOV 114
DEP has provided this form for use by local Boards of Health. Other forrrtbM i be used, but the
information must be substantially the same as that provided here. E 11 with your
local Board of Health to determine the form they use. The System Pumping Feci tObNTsubmitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
k Facility-,-'-—--......I-nformation
Important:When
filling out forms 1. System Locat 10
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code
2. System Owner:
rob
01-I
Name
------------
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank eGrease Trap
❑ Other(describe):
4. Effluent Tee Filter present? El Yes ❑ No If yes, was it cleaned? ❑ Yes El No
5. Observed
condition of component pumped:
-90--bc-t---------------
6.(lystsm Pumped By:
Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20"7giu-mill-stbradford ma
Signature of Haiif Date
-------------
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc-11/12 System Pumping Record-Page 1 of 1