HomeMy WebLinkAboutGrease Trap, Sludge Tank, Septic Tank, Septic Tank - Septic Pumping Slip - 351 WILLOW STREET 3/15/2022 �Ec�r9
Commonwealth of Massachusetts R 152022
City/Town of No. Andover MA ovE�
�H ANp
° System Pumping Record �OWNQFNDEpAqaM�Nj
C4 Form 4 ViSM.TN
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, 1l� ►n��'(D S�
use only the tab v v
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
r� 2. System Owner:
Name
ream
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: ElCesspool(s) ElSeptic Tank ❑ Tight Tank rease Trap
❑ Other(describe): �-
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component mped: w
6. S�% umped By:
ame Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were dis ed:
2 So.-Mill S ., Bradford -
Ha Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
FtECE1VEL,
Commonwealth of Massachusetts MAR 15 Jai
w W City/Town of No. Andover
a System Pumping Record TOWNOFNOt�fMANDOV�R
C Form 4 ,�Ep,�TH 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, l�.,, f
use only the tab VV 1 v W
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
9
Name------ —
nnm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Z�I o -z z. 2. Quantity Pumped: 5
Date Ga 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 compoPP mped:
6. S�em By:
A� Q—
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill d, MA
ature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
1�. Commonwealth of Massachusetts RECEIVED
= City/Town of No. Andover
System Pumping Record MAR 15 2022
Form 4
M TOWN OF NORTH RAN�11DOTER
DEP has provided this form for use by local Boards of Health. Other fom1daAhjl'tli9Fased, 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 �+('�
use only the tab 7 �/V r I,{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:
rah
Name
remm
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 L-Ko If yes, was it cleaned? ❑ Yes M—No
5. Observed condition of compo ent pumped:
C
6. System j ww t�v�
Name j'J �•L 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
RECEIVE[)Commonwealth of Massachusetts
hI City/Town of No. Andover MAR 15 2022
I^I System Pumping Record
Form 4
M TOWN AOF NOR'fH L DEPARTMENT
NT
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 J� t
use only the tab Is- �/1/
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
11 2. System Owner:
Name
remm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date ( Z� 2. Quantity Pumped: Gallons`v
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
�r
her(describe): /✓ ��e / —
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped Bye_
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 HauTer Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1
jECENEt
ICN- Commonwealth of Massachusetts BAR 151W
City/Town of
System Pumping Record �Owt4n�NOR, MEND
r Form 4 HENt VA c�Epa..
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 Al
key to move your Address
cursor-do not MA
use the return City/Town State Zip Code
key.
2. System Owner:
Y�
Name
tam
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Da Quantity Pumped: Gallo
rfs
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank Vase Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 13' o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of componen#gttmped: /
6. Sy a umped By: r
Name. Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 $o. Mill ., Bradford,
igna 9f a ,r Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
�EGEtVE®
Commonwealth of Massachusetts R 152022
W City/Town of No. Andover Ma ovE�
System Pumping Record NofNORP a MEN
Form 4 �CNEp,)SH�E
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, 3 (,t/i
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:
N �--
Name
�n
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
2 0 o
1. Date of Pumping Date (�' Z 2. Quantity Pumped: Gallon
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: A
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
ID
Commonwealth of Massachusetts �EGEIvE
u W City/Town of No. Andover MAR 152022
System Pumping Record ANoovEk
Form 4 10*0 OSH oEPA SMSON
M HEN
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, / f� /I
use only the tab _ V V l4 J7
key to move your Address
cursor-do not No. Andover MA
use the return City/Town State Zip Code
key.
2. System Owner:
Name ----
reem
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Z 2. Quantity Pumped: -
Date Gallons
3. Component: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes d No If yes, was it cleaned? ❑ Yes No
5. Observed condition of comppnent pumped:
6. System Pumpe�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• 11/12 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
r 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,
use only the tab
key to move your Address
cursor-do not
use the return key. City/Town State Zip Code
2. System Owner: go(g
/A) td "
Name
rertm
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: Gallons
3. Component: ❑ Cesspool(s) ❑--Septic Tank ❑ Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LAo If yes, was it cleaned? ❑ Yes ff/No
5. Observed condition of compone pumped:
6. Syst m Pumped By: �.1CJ�'O�'�- O JVP
Name Vehicle License Number N�� P�lM
Company s Septic 58 So Kimball St. , Bradford,MA �G N�p�Np�P
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