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Home My WebLink AboutGrease Trap, clean out, & Sludge Tank - Septic Pumping Slip - 351 WILLOW STREET 8/9/2021 �L\ Commonwealth of Massachusetts W City/Town of No. Andover System Pumping Record RECEIVED Form 4 AUG 0 9 2021 'GSM VER DEP has provided this form for use by local Boards of Health. O� d, but the information must be substantially the same as that provided her . Ftl 9�� Is 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, / All use only the tab U� key to move your Address cursor-do not No. Andover MA 01845 use the return key. City/Town State Zip Code 2. System Owner: �I Name ---- -- rtem Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gall 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank s rease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes Z11 o If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pu d: Ls 6. st m Pu ped By: �— hq e Name Vehicle License Number Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were dispos d: f2S . ill St., Bradford, MA �are �Rin�aciiitv Date Same day Sig (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 System Pumping Record AUG 0 9 M1 u Form 4 TOWN OF NORTH AND01MR 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 01845 use the return City/Town State Zip Code key. r� 2. System Owner: Name 2rom Address(if different from location) No. Andover City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s)� � E Septic Tank ❑ Tight Tank ❑ Grease Trap `4 Other (describe): C-p"- " ` - 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 6. System Pumped By: �_zv Name 41 V I 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 Commonwealth of Massachusetts x W City/Town of No. Andover RECEIVED m System Pumping Record AUG 0 G ZO Form 4 TOWN OF NORTH ANDDVER DEP has provided this form for use by local Boards of Health. Other form4l �41 e used, bN i t 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 ]7 VV J key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. t� 2. System Owner: Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record n 1. Date of Pumping 2. Quantity Pumped: 51 CDC) 1 Date Gallons 3. Component: ElCesspool(s) ElSeptic T k ❑ Tight Tank Grease Trap ❑ Other(describe): — - --- 4. Effluent Tee Filter present? ❑ Yes eNo If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of compCnt pumped: �J4 6. Syste ed By: 12 Name Vehicle License Number Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were disposed: 071VI'M t., Bradford,.-MA- 7�7 Y-2 Signature o 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 AUG 0 9 2021 System Pumping Record TOWN OF NORTH ANDOVER Form 4 HEALTH 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 VV 1 v vy key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. 2. System Owner: It Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping ? 2. Quantity Pumped: Gov Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap S) Other(describe): --- -- 4. Effluent Tee Filter present? ❑ Yes 2-'No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: A � 6. S�ysstt�em Pumped By:`f 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�C� 1 vJ 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 W City/Town of No. Andover RECEIVED System Pumping Record AUG 0 9 2021 Form 4 OF NORIH TO HFFALTH DEPAR M NT R 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, 3 r-( I^�//4`✓ (.� use only the tab V v J _ key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. 2. System Owner: Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 7 z- ^ 2. Quantity Pumped: Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ElTight Tank rease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes vffo� If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of compone�tuniped: 6. Syst Pumped By: 111 / Name Vehicle License Number Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were d' osed: 20 S St., Bradford, Date Same day Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1