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HomeMy WebLinkAboutSludge Tank, Grease Trap, - Septic Pumping Slip - 351 WILLOW STREET 5/5/2022 Commonwealth of Massachusetts RECEIVED City/Town of No.Andoyer MAY 0 5 2022 System Pumping Record T�,I-�.,of NORTH ANDovEI Form 4 HLALTH 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 onlylythethe tab key to move your Address cursor-do not use the return City/Town State Zip Code key. �� 2. System Owner: r �12 Name reosn Address(if different from location) No.Andover MA City/Town State Zip Code Telephone Number B. Pumping Record 35o'1. Date of Pumping Date q�p4�� 2. Quantity Pumped: 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: -qood 6. System Pumped By: Name o Vehicle License Number Stewart's Septic 58 So Kimball St. , Bradford,MA Company 7. Location where contents were disposed: 20 So.Mill St.,Bradfor ,MA i r Dae •/ Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts RECEIVED 4 W City/Town of No. Andover System Pumping Record MAY 0 5 2022 Form 4 OWI I 0l+NORTH ANDOVER HE _TH 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. t� fi` 2. System Owner: ,,* �J© Name 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 14 No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of componef t pumped: 6. System Pumped By: Name ° Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service, 58 So. Kimball St., 7. Location where contents were disposed: Stewart's GI bal Enviro LLC, 20 So. Mill St., Bradford, MA 01835 Same day S' ature ofqauler Date Same day Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1 8ECOVEL Commonwealth of Massachusetts 3 k City/Town of No.Andoyer MAY 0 202 System Pumping Record Trr NN OF NORTH ANDOVElr. - 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, / 1 use only the tab key to move your Address cursor-do not use the return City/Town State Zip Code key. 2. System Owner: Ud N ' Name room Address(if different from location) No.Andover _ MA City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: r Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank rease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes o EA�lf yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 6. Sy mped By: 3 ro'�) P/ny' _ 3 Na 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 Sign ure of a er Date IV' i ity(�sttachfacility receipt) Date t5form4.doc• 11/12 System Pumping Record •Page 1 of 1 Commonwealth of Massachusetts RECEIVED U W City/Town of No. Andover MAY 0 5 2022 a System Pumping Record Form 4 TOWN OF NORTH ANDOVER M 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. 2. System Owner: IN , J Name _ _ I Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date r / / Z Z 2. Quantity Pumped: Gallons r 3. Component: ❑ Cesspool(s) ❑ Septic Tank ElTight Tank rease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component umped: r_� c�C) SIB 6. Sy=pumped By: Name Vehicle License Number Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were disposed: 2 I radford, MA ignat re of Hauer Date Same day Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1 RECEIVED Commonwealth of Massachusetts = City/Town of No.Andover MAY 0 5 2022 System Pumping Record :NI O TH ANDOVER Form 4 SHE :H CEPA'RTMENT 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 & •&7v a� s key to move your Address cursor-do not use the return Cityfrown State Zip Code key. 2. System Owner: fy red / Name reern Address(if different from location) No. Andover MA City/Town State Zip Code Telephone Number B. Pumping Record �d 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 VNo If yes, was it cleaned? ❑ Yes eNo 5. Observed condition of component pumped: 6. System Pumpe By: r 0 klrf v 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