HomeMy WebLinkAboutGrease Trap, Sludge Tank - Septic Pumping Slip - 351 WILLOW STREET 11/8/2021 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, W t r1 �
use only the tab —__ _ J
key to move your Address
cursor-do not No. Andover MA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
,a Al
Name -- —
renm
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 El Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of componenn trumped:
6. umped By: :3�3
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 o. ' t., Bradfor ,
Signature of Ha 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
SI 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: r
n /
on the computer, �l
use only the tab
key to move your Address
cursor-do not
use the return City/Town State Zip Code
key.
2. System Owner:
;�t Kt
Name
reran
Address(if different from location)
No Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
b-'Z S- 2/ H 0 00
1. Date of Pumping ate 2 Quantity Pumped. Ga Ions
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe): S I� �&
4. Effluent Tee Filter present? ❑ Yes �No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
aa�d
6. System Pumped y:
Name c 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
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
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 / I /( "
use only the tab - _) ►'V' f I Q
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
recur
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
oy
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) El Septic Tank El Tight Tank El Grease Trap
Other(describe): S/
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed c dition 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, MAto-
/ J
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1
IL
Commonwealth of Massachusetts
City/Town of No. Andover
W° System Pumping Record
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, 3�/ W/ //O k f
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)
Citylrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping pate — 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
c�—
Other(describe): �SE� �'
4. Effluent Tee Filter present? ❑ Yes C"o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped)�- I2
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So ill 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
IL
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 only
computer, i ,{ ((�
use only the tab Vlf�
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
0-1) 2. System Owner:V I A ) �o
� /v 4'
Name ---- — ---- ---
rtua
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 C&No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
lTa4�
6. System Pumped By:
jC411e s
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, �4&
�J �-
ignature 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
W City/Town of No. Andover
W° 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 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:
�jQ
Name
rendn
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. Compon nt: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑ Yes tom,No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
G7 cv���
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 ill St., Br ord M
4
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1