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Home My WebLink AboutGrease trap, septic tank, sludge tank, - Septic Pumping Slip - 351 WILLOW STREET 9/7/2021 Commonwealth of Massachusetts RECEIVED (� City/Town of No. Andover SEP 0 7 2021 System Pumping Record TMN OF NMI1 MDINIR Form 4 WALTH C 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, mputer, r� use onlythe tab (lj� J tT�2.a j key to move your Address cursor-do not 01845 use the return City/Town State Zip Code key. r� 2. System Owner: f ;'2'�x' !i Name rtman 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: �alions 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank XGrease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 6ed 6. System Pumped By: Name 1/ 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 RECEIVED N W City/Town of No. Andover W° System Pumping Record ��.P 0 7 2021 a TOWN OF NORTH ANDOVER Form 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 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: / on the computer, 351 K/WoW S� 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 —..-- relun 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) [3'Septic Tank ❑ Tight Tank [:1 Grease Trap ❑ Other(describe): — 4. Effluent Tee Filter present? ❑ Yes UE No If yes, was it cleaned? ❑ Yes E]r No 5. Observed condition of compon�t pumped: r� 6. System Pumped By: PO4N-e,VU C� 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 Commonwealth of Massachusetts RECEIVED W City/Town of No. Andover a System Pumping Record SEP 0 7 10?1 Form 4 'SOWN OF NORTH ANDOVER �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, juf/ ',�/� use only the tab /J �'l` key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. 2. System Owner: t� / lac /I� Joy Name ranm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date �/ 2. Quantity Pumped: Gallons Lr 3. Component: ❑ Cesspool(s) Sept Tank El Tight Tank El Grease Trap ❑ Other(describe): ✓1 4. Effluent Tee Filter present? ❑ Yes R31to If yes, was it cleaned? ❑ Yes Mlo 5. Observed condition of compon pumped: 6. Sy tem�Pumped By: t '1-.N'vt' N me 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 RECEIVED W City/Town of No. Andover System Pumping Record SEP 0 7 2071 Form 4 TOWN OF NORTH ANDOVER " HEALTH DEPA:T%1ENT 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, 361 �� ,,do W_,,use only the tab V 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: :. j G6X f� ifjI/A /r Name ------ p eam Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) EfSeptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes �T/No 5. Observed condition of componen pumped: 6. SystW Pumped By: L/ 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 RECEIVED = W City/Town of No. Andover SI;f' 0 7 System Pumping Record TOWN OF NURI H ANUUVER 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 key to move your Address cursor-do not No. Andover MA 01845 use the return CityTTown State Zip Code key. 2. System Owner: L�- Name ,e1un 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 LI/No If yes, was it cleaned? ❑ Yes E]--'N"o 5. Observed condition of componel t 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• 11/12 System Pumping Record•Page 1 of 1