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HomeMy WebLinkAboutGrease Trap, Sludge Tank, EQ Tank, - Septic Pumping Slip - 351 WILLOW STREET 10/7/2021 Commonwealth of Massachusetts RECEIVED W City/Town of No. Andover H - System Pumping Record a � Form 4 TOWN OF NORTH ANDOVER w 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 City/Town State Zip Code key. �1 2. System Owner: Name rrmm 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: ElCesspool(s) El Septic Tank ElE;4as Tight Tank e Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component umped: 6. Syst u ped By: Name Vehicle License Number Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were disposed: 2 t., Bradford, MA re o au Date v 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 a 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, j/ I -� /CW use only the tab key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. 2. System Owner: 'Al ' 0 Name --- -- - - - ienm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record �- z�- zr 4() 1. Date of Pumping Date 2 Quantity Pumped: GalIons 3. Component: ❑ Cesspool(s) /❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): S u 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 1 6. Systeped By: Y%Q - A��� Name Vehicle License Number Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were disposed: 20 So. Mill radford, MA q--d cl � nature ofl4iuler 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 City/Town of No Andover TOWN OF NORTH ANDOVER System Pumping Record Y p 9 HEALTH DEPARTMENT iG^M 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, 05 use only the tab ; r I LU key to move your Address cursor-do not use the return City/Town State Zip Code key. 2. System Owner: UA Im,Vic Name ream Address(if different from location) No Andover MA City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping p 2. QuantityPumped: DateGallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap cam!'-. Other(describe): Isk` '�("_ '� 4_ /4-- 4. Effluent Tee Filter present? ❑ Yes ®'No If yes, was it cleaned? ❑ Yes ❑ No 5. Ol;erved ppndition of component pumped: 6. System Pumped 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 �G Ace s Signature of Hauer Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 <�N Commonwealth of Massachusetts W City/Town of No. Andover RECEIVED System Pumping Record Form 4 TO'Y,'N'C NCRTFI PN'DOVER DEP has provided this form for use by local Boards of Health. Other,forms,may bfe 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 City/Town State Zip Code key. �I1 2. System Owner: y� I Name - - — — etun Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2� 2. Quantity Pumped: SDO0 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: 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 l4EGE'I!/E® City/Town of No. Andover a System Pumping Record TOWN OFNORTHANDOVER 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: //JJ on the computer, use only the tab 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 Date 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): 4. Effluent Tee Filter present? ❑ Yes 2--N o If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: /QC, r, .� - 6. System Pumped OName 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 , a E-5 S gnature 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 TO'-','; N' "!H/-' d YJVEi? 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 City/Town State Zip Code key. 2. System Owner: Name ----- \ �rsn Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 6 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: �( 1 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 Commonwealth of Massachusetts �1 W City/Town of No. Andover RECEIVED System Pumping Record C;T f ,M Form 4 TOWN OF NORTH ANDOVER 1, DEP has provided this form for use by local Boards of Health. Other forms may be Jsed, 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. r� 2. System Owner: Name _ Address(if different from location) Cityr State Zip Code Telephone Number B. Pumping Record q/V I 1. Date of Pumping 2. Quantity Pumped: 9000 Date i 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: Name Vehicle License Number Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were disposed: 20 So. VII St., Bradfor , M /,/,I- 4'�-U�/ \J- Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11112 System Pumping Record•Page 1 of 1