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HomeMy WebLinkAboutSludge Tank, Sludge, Septic Tank - Septic Pumping Slip - 351 WILLOW STREET Commonwealth of Massachusetts RECEIVED w W City/Town of No. Andover MAY 0 5 2022 - System Pumping Record Form 4 T� `'` "' ' � ANDOVER f�:.Th,: _:-`ARTMENT 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 VV, J74 key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. ,a 2. System Owner: ` rN' T Name razun Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record Y s q- 1 Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ElSeptic Tank ❑ Tight Tank [IGrease Trap E111*0&her(describe): -S`CId[Qq 4. Effluent Tee Filter present? ❑ Yes 2-"No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: Gae S 6. System Pumped By: `` - �.�2 ame Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service, 58 So. Kimball St., 7. Location where contents were disposed: Stewa 's Global Wnvironmental, LLC, 20 So. Mill St., Bradford, MA 01835 Same day Sign ture 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 RECEIVED Commonwealth of Massachusetts City/Town of No. Andover MAY 0 2022 System WN OF NORTH ANDOVER Pumping TO Y p g Record HEriL'TH CEPARTMENT 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/// w use only the tab 4 key to move your Address cursor-do not No. Andover MA 01845 use the return Citylrown State Zip Code key. 2. System Owner: r� r Name room Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping -/'ZZ L� 2. Quantity Pumped: �30oo -- -- Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap [Other(describe): `S� - 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: &LI,, 6. System Pumped By: J1 f' 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: Stew rt's Global Environmental, LLC, 20 So. Mill St., Bradford, MA 01835 ('1 Same day Signature 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 MAY 0 5 2022 City/Town of No.Andover tx; = TC;f/N OF NORTH ANDOVER System Pumping Record E:�t.TNDEPARTMEN7 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 City/Town State Zip Code key. 2. System Owner: Name rerun 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) E71"Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes V'�No If yes, was it cleaned? ❑ Yes [t N 5. Observed condition of coAmpoonent p ped: 6. System Pumpp B 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