HomeMy WebLinkAboutgrease trap, septic tank and sludge tank - Septic Pumping Slip - 351 WILLOW STREET 3/2/2021 Commonwealth of Massachusetts
MAaV _ W City/Town of No. Andover
System Pumping Record
Form 4
cGM
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 / �l 1
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
11 2. System Owner:
Name— --- ----- -
n�
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record �7
1. Date of Pumping / — L' 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank 29-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: ea4,4
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., radford,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•11/12 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 / �t vl// ( U v�w
y 151L,
key to move your Address
cursor-do not No. Andover MA
use the return Cityfrown State Zip Code
key.
2. System Owner:
� 4
& AJ 4
Name -- — --
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping to 2. Quantity Pumped: Gal
lons
3. Component: ❑ Cesspool( ❑ Septic Tank ❑ Tight Tank rGrease Trap
2 O her(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
V G Cj C g-,—
6. System Pumped BB
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
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
System Pumping Record
Form 4
�M
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 I/�/V" r�D� _
key to move your Address
cursor-do not No. Andover MA 01845
use the return Cityrrown State Zip Code
key.
2. System Owner:
Name
germ
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping _ ' 2( 2. Quantity Pumped:
Date Gallons
3. Component: ElCesspool(s) ❑ Septic Tank El 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 p ed:TT
6. Syst ped By:
I ( )C� _2
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
So. RirSt., Bradford, /
Signature of 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
M
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, ,,, I�, l,� ��
use only the tab _ _ l �/" �/
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
r� 2. System Owner.-
Name ---
ieam
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
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes []-No If yes, was it cleaned? ❑ Yes B-'No
5. Observed condition of component pumped:
6. System Pumped
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•11/12 System Pumping Record•Page 1 of 1