Loading...
HomeMy WebLinkAboutCatch Basin / Grease Trap - Septic Pumping Slip - 351 WILLOW STREET 7/7/2021 Commonwealth of Massachusetts RECEIVED T W City/Town of No. Andover System Pumping Record JUL 0 1207.1 Form 4 TOWN OF NORTH ANDOVER 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 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 No. Andover MA 01845 use the return key. Cityrrown State Zip Code t� 2. System Owner: Name seam Address(if different from location) Cityrrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2� 2. Quantity Pumped: �Uoo 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: 'SI"x'p- 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 Same day Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts RECEIVED s City/Town of No. Andover JUL 0 7 2021 System Pumping Record TOWN OF NORTH ANDOVER Form 4 HEALTH DEPARTMENT <c cM 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 �`I �li LlJ V key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. 2. System Owner: rrb Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Da e / Z 2. Quantity Pumped: Gallons 0 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: 99DO4 L) 6. System Pumped By: 101 * JqA-< _ 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 /rSignatur Date Same day Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 a � Commonwealth of Massachusetts RECEIVED City/Town of No. Andover R System Pumping Record JUL 0 7 207.1 a Form 4 M 5 TOWN OF NORTH ANDUVER DEP has provided this form for use by local Boards of Health. Other fdrmsEALTH mayDEPQR Re useTMENj', 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 V v y vV key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. 2. System Owner: rah ,/V I 0 Name --- r�m Address(if different from location) Cityrrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date � 2. Quantity Pumped: Gains-- 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pu ed: 6. Sys te mped By: �— Name Vehicle License Number Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were disposed: 20 o. Mill-St, Bradford, MA Si of uler Date Same day Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts RECEIVED W City/Town of No. Andover M- 0 7 2021 W49System Pumping Record TC'NNOF NORTH ANDOVER Form 4 HEAU DEPARTMENT ' 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 key to move your Address cursor-do not No. Andover MA 01845 use the return Cityrrown State Zip Code key. 2. System Owner: Name --- -— 6,�e- '/1/ ( `lo �un Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record - 1. Date of Pumping 2-4 Date JI 2. Quantity Pumped: Gallon 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank Ff Grease Trap ❑ Other(describe): -- S 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., Bradford, MA Signature of Hauler Date Same day 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 JUL 0 7 2021 System Pumping Record Form 4 T�HHEEAOTH 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 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer,use only the tab LM t//__ w ki S key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. 2. System Owner: tab N J OL Name nam Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date �- z ' 2. Quantity Pumped: Gallon er' 3. pone t: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ease Trap Other(describe): G(I f 4. Effluent Tee Filter present? ❑ Yes Imo If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 6. Sy T m ped By: �— NaTrre— Vehicle License Number Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were disposed. 20 S . Mill S ., Bradford, M nature of Haul Date Same day Signatur eceiving Facility(or attach facility receipt) Date t5form4.doc• 11112 System Pumping Record•Page 1 of 1