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Home My WebLink AboutGrease Trap & Sludge Tank - Septic Pumping Slip - 351 WILLOW STREET 1/19/2022 RECEIVEC Commonwealth of Massachusetts City/Town of No. Andover JAN 19 Z022 System Pumping Record TOWN OF NORTH ANDOVU Form 4 HEALTH DEPARTMENT GSM 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, r�0 1'j use only the tab key to move your Address cursor-do not No. Andover MA use the return City/Town State Zip Code key. r� 2. System Owner: L iA/ � I� Name - rendn Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record �13 ./Z-/ — 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: ElCesspool(s) ElSeptic Tank ❑ Tight Tank rease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes Ur No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pu �d: � 6. Syst Pumped By: �^ -- Name Vehicle License Number Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were disposed: 20 Ss.-Ml Bradford, MA re—of Date Same day Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 RECENEri Commonwealth of Massachusetts W City/Town of No. Andover JAN 192022 System Pumping Record TOWN OF NORTHANDOVER 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, /� J � use only the tab V / nUL key to move your Address cursor-do not No. Andover MA use the return City/Town State Zip Code key. 2. System Owner: rah , / T Name nam Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: ns �� Date Gallons 3. Component: ❑ Cesspool(s) ElSeptic Tank ❑ Tight Tank F6rease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of compone umped: 6. Syst Pumped By: 0n Name Vehicle License Num er Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were disposed: _ r O So Mill Bradford, MA Signature of a 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 BAN 920�2 W City/Town of No. AndoverWWI o �t3 HNVOvt' System Pumping Record �pvjepa r'EpAOVMENT 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, I t q I r(Q use only the tab key to move your Address cursor-do not No. Andover MA use the return City/Town State Zip Code key. 2. System Owner: Name — ienm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record E^ 1. Date of Pumping 2. Quantity Pumped: J Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank rease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes [ tQ0 If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component niumped: 6. Syste P ped By: - --rir Z3 Name Vehicle License Number Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were dis�osed: 20 So. Mill St.?, Bradford, MA L ure ule Date Same day Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1 ;FC;F_IVF+ Commonwealth of Massachusetts JAN 192022 City/Town of No. Andover System Pumping Record TOHEALTH DEPAR MENT& Form 4 7M 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, "�' 'n,I //o� C� use only the tab l/ V V t �/ key to move your Address cursor-do not No. Andover MA 01845 use the return -- key. City/Town State Zip Code t� 2. System Owner: - -- -- &At rN I .toy Name . nom Address(if different from location) City/Town State Zip Code Telephone Number B. Dumping Record 1. Date of Pumping Date 2 Z 3 2. Quantity Pumped: gall ons 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 Si nature 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 JAN 19 2022 City/Town of No. Andover TOWN OF NORTH ANs0OVEF System Pumping Record HEALTH DEPARTMENT 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: 2 / � � �IC� �� on the computer, 7 /j�f use only the tab key to move your Address cursor-do not No. Andover MA use the return key. City/Town State Zip Code 2. System Owner: Name nnrn 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 Eq- rease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes 9-Nb If yes, was it cleaned? ❑ Yes ❑'lqo 5. Observed condition of compo ent pum� i: 6. System Pum d 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• 11112 System Pumping Record•Page 1 of 1 RECEIVED Commonwealth of Massachusetts JAN 19ZOZZ City/Town of No. Andover TOWN OF:NORTH ANDOVER System Pumping Record HEALTH DEPARTMENT 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 �G� S� use only the tab �/ J� llV L key to move your Address cursor-do not use the return City/Town State Zip Code key. 2. System Owner: z /Ij d Z Name rartm Address(if different from location) No. Andover MA City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallon 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 wnped: / 6. Sy umped By: t Name Vehicle License Number Stewart's Septic 58 So Kimball St. , Bradford,MA Company 7. Location where contents were disposed: 2 Mill S ., radford,MA Signature auler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1