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Home My WebLink About- Septic Pumping Slip - 351 WILLOW STREET 3/13/2019 Commonwealth of Massachusetts ,y x City/Town of No. Andover � _ System Pumping Record Form 4 y k V �� r DEP has provided this form for use by local Boards of Health. Other forms ray be used, but the 1 information must be substantially the same as that provided here. Before using this form, check with your I 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. t 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 No. Andover MA 01845 use the return . _.. _. key. City/Town State Zip Code t� 2. System Owner: Name rertm 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 ❑ Grease Trap ther(describe); U ?, r� 4. Effluent Tee Filter present? ❑ Yes [ Kc, If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 4116- ' _ — 6. System Pumped B Name Vehicle License Number Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were disposed: 20 So. Mill St., Brad -d,,MA ---------- Signature of Hauler Date _ _._.... Signakure of Receiving Facil- itiky(or attac-h facility receipt) Date i t5form4.doc•11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts u City/Town of No. Andover - System Pumping Record Farm 4 �,��. �•i�,iiii(II�Yti:b�u'�. R " ' V 6�GJmVr��'b6k'GB � f 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 ito determine the form they use. The System Pumping Record must be submitted to j the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CM 15,351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab 1 l ( ., �•; Y ...... ..... ... key to move your Address cursor-do not No. Andover MA 01845 use the return _.— ........�._......._..._ key. City/Town State Zip Code 2. System Owner: tab1. A Name 11 ranan Address(f different from location) City/Town State Zip Code Telephone Number B. Pumping Record Dat + 1, Date of Pumping - - 2. Quantity Pumped: D3 iat1-allons Jr 3. Component: ❑ Cesspool(s) ® 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: . -....._m._. r._ o.J'.... _ "' 6. System Pumped By: _. .. � .... -- _.__,,,........ Name j 11 Vehicle License Number Stewart's Septic 58...Sa Kimball St,, Bradford,MA Company 7. Location where contents were disposed: 20 So. Mill St „Bradford, MA n re auler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts M City/Town of No. Andover System Pumping Record 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 farm 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: an the computer, use only the fob .-- key to move your Address cursor-do not No. Andover MA 01845 use the return key. City/Town State Zip Code f� 2. System Owner: Name tenor Address(if different from location) — Citylrown 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 ❑ Grease Trap r Other(describe): -- 4. Effluent Tee Filter present? 0 Yes ®"'No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 6. System Pumped g Name Vehicle license Number Stewart's Septic 58 So. Kimball St. Bradford,MA Company 7. Location where contents were disposed: 20 So. Mill St., Bradferd;-MA Signature of H er Date Signature of Receiving Facility(or attach facility receipt) Date t5forrn4.doc-11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts 0''� r - City/Town of No. Andover System Pumping Record 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 1 key to move your Address cursor-do not No. Andover MA 01845 use the return _ —.. key. City/Town State Zip Code 2. System Owner: rab Name ren�e 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 ❑ Grease Trap f El Other(describe): / f1:..... l .� ............. _ 4. Effluent Tee Filter present? ❑ Yes ❑-N`b If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 6. System Pumped By: 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 Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11112 System Pumping Record-Page 1 of 1 Commonwealth of Massachusetts City/Town of No. Andover System Pumping Record 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 / 0116 key to move your Address cursor-do not No. Andover MA 01845 use the return __....____..._..m_ . .....__. key. City/Town State Zip Code 2. System Owner: red tiMJ� ,ry.. Af Name _.__......._ .._.. lBAMA Address(if different from location) _ _.._......_ _.... __......-w____ _...... City/Town State Zip Code Telephone Number B. Pumping Record . ' c.� 1. Date of Pumping _ . '� ...�-�_......�. .....,.... 2. Quantity Pumped: _.......... _.._. Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank 1m ight 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: ��t C�V 6. System Pumped B r .___ ._..__ ......� ..____.___.... ........ ..............— 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 i Signature of Hauler Date i Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts W City/Town of No. Andover n System Pumping Record Form 4 rr 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 j accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab w �_.� ut�1 .t�..... _ .!_.... _..__._.... key to move your Address cursor-do not No. Andover MA 01845 use the return �_ _ _......_............ _........ _...__.,. _....... key. City/Town State Zip Code Q2. System Owner: ".w Name __.... ..w _.._. ierwn ___......_.�.. _. _, ... _.._ ............ .. Address(if different from location) City/Town State Zip Code —__ .......... .... . ........._....,_. _ Telephone Number B. Pumping Record 1. Date of Pumping Date - — 2. Quantity Pumped: allons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ® Tight Tank ❑ Grease Trap 1 �Ff Other(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 Stewart's Septic 58 So. Kimball St., Bradford MA Company 7. Location where contents were disposed: 20 So. Mill St.,B adford, MA g to o auler Date Signature of Receiving Facility(or attach facility receipt) Date i t5form4.doc•11/12 System Pumping Record-Page 1 of 1 pm i Commonwealth of Massachusetts M u City/Town of No. Andover System Pumping ec r Fora �`�;;,;1'�°<<,a�.Er.E�,.� , I 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: computer,use o " mob��`" 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 2. System Owner: Name e2rn Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping ecor 1. Date of Pumping _ 2. Quantity Pumped: -- Date Gallons 3. Component: ❑ Cesspool(s) 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: / 6. System Pumped By: f Name Vehicle License Number Stewart's Se tip `c 58 Sq. Kimball St. Bradford,MA Company i 7. Location where contents were disposed: 20 So. Mill St., Bradford MA i Signature of Hauler Date i Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc-11112 System Pumping Record•Page 1 of 1 E Commonwealth of Massachusetts City/Town of No. Andover System Pumping Record 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 (o 6 key to move your Address cursor-do not No.Andover use the return MA 01845 key, CityfTown State Zip Code 2. System Owner: rib 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 El Tight Tank El Grease Trap R Other(describe): 4. Effluent Tee Filter present? F-1 Yes Er-No If yes,was it cleaned? ❑ Yes RIM 5. Observed condition of co pone p roped: 6. System Pumped Name Vehicie License Number Stewart's Septic 58 So. Kimball St., Braqfqrd,MA Company 7. Location where contents were disposed: 20 So. Kill St,, Bradford,M&_ Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc-11/12 System Pumping Record-Page 1 of 1