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HomeMy WebLinkAboutSludge Tank, Grease Trap, Septic Tank - Septic Pumping Slip - 351 WILLOW STREET 4/20/2022 �ECEIVEL Commonwealth of Massachusetts PR 2 02022 City/Town of No. Andover A ` ,'v System Pumping Record or i��"�` ENT TC�f I,aI.TH 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 key to move your Address cursor-do not No. Andover _ MA 01845 use the return City/Town State Zip Code key. 2. System Owner: �� � tv rab �J Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 2q Z� <7O0 1. Date of Pumping — — 2. Quantity Pumped: -- - Date Gallons 3. Component: ❑ Cesspool(s)) ,,��0 Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): J �'A� 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: �d 6. System Pumped 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 n e ul Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts tiotiti �, 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 City/Town State Zip Code key. 2. System Owner: 195 Name tz re�um Address(if different from location) No Andover MA City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping U' �2 Quantity Pumped: Date Gallon 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank rease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of compon t pumped: 0� rl 6..Sys m Pu ed B Na Vehicle License Number o Stewart's Septic 58 So Kimball St. , Bradford,MA Company 7. Location where contents were disposed: 20 $o.Mill St:; adford, re of uler Date Signatu of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts �o���'�© N W City/Town of No. Andover System Pumping Record P ��APNp�0 Form 4 �O`NC�PL N�EPP��M 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: V on the computer, /���� use only the tab V �i key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. 2. System Owner: T I/U I y o Name — 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 "o- If yes, was it cleaned? ❑ Yes Erl o 5. Observed condition of compo nt pumped: 6. System Pumped Bar: iAlt1w C11. 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 �ECENEU 'L\ Commonwealth of Massachusetts R 2 01022 City/Town of No. Andover AP Or System Pumping Record NNURT" -TMEw k R Form 4 �OHEAL�HpEpA 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, r use only the tab Ck key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. 2. System Owner: r � Name--- - 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( ) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): 5ia ��� 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed rn dition of component pumped: CrQ/ ( 6. System Pump5e'd�y: 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 ford, 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 tleCEIVEU � Commonwealth of Massachusetts W City/Town of No. Andover pFR 2 p 2022 a System Pumping Record NOFNOR�H SMENT R Form 4 �OHEp,LTH pEPAR �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 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 — �evn Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date — 2. Quantity Pumped: G nons 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 4D'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 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1