HomeMy WebLinkAboutSeptic Tank, Sludge tankt, Grease Trap - Septic Pumping Slip - 351 WILLOW STREET 6/7/2022 RECEIVED
_ . Commonwealth of Massachusetts
City/Town of No.Andover JUN o 7 2022
System Pumping Record TG'?r'N OF NORTH ANDOVER
Form 4
HEALTH DEPARTMENT
�M v
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
ream
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date f 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes N�/No If yes, was it cleaned? ❑ Yes Eil�o
5. Observed condition of com onent pu ped:
6. System Pumped By:
p e r'�j-e11tn1-G
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
RECEIVED
�LN Commonwealth of Massachusetts
W City/Town of No. Andover JUN 0 7 2022
a System Pumping Record TCI` IN uF NORTH ANDOVER
Form 4 ,;tALTH 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, M ( '0( S
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
ream
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 7� L� 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
)01*-O-ther(describe):
4. Effluent Tee Filter present? ❑ Yes �<o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped::
6. stem_Pumped By:
��'�' gj'ap-
Name Vehicle License Number
AS Development Corp. d/b/a
Stewart's Septic Service, 58 So. Kimball St.,
7. Location where contents were disposed:
Stewart's Global Environmental, LLC, 20 So. Mill St., Bradford, MA 01835
Same day
to f Hauler Date
Same day
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
HECEtVED
Commonwealth of Massachusetts
City/Town of No. Andover ��N p 2022
° System Pumping Record OF NCµ fN ANDovER
N -fMENT
Form 4
TOHEALI DEPAR
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, / /)/� ffe , 1�use only the tab1/V
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
ream
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) 23/3'eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): —
4. Effluent Tee Filter present? ❑ Yes I�No If yes, was it cleaned? ❑ Yes�No
5. Observed condition of co mponent mped:
V' v'
6. System urm-�p"e"d�By":
-
Name Vehicle License Number
AS Development Corp. d/b/a
Stewart's Septic Service, 58 So. Kimball St.,
7. Location where contents were disposed:
Stewart's Global Environmental, LLC, 20 So. Mill St., Bradford, MA 01835
Same day
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
RECEIVED
Commonwealth of Massachusetts
W City/Town of No. Andover JUN 0 7 2022
System Pumping Record TOWN OF NORTH ANDOVER
y p g HEALTH DEPARTMENT
Form 4
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,
use only the tab
key to move your Address
cursor-do not No. Andover MA 01845
use the return Cityrrown State Zip Code
key.
2. System Owner:
Name
renm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
2 3
1. Date of Pumping Da to 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank 9
1 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
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
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Commonwealth of Massachusetts RECEIVED
City/Town of No. Andover
System Pumping Record JUN 072022
` Form 4
N...MTH ANMDOVER
DEP has provided this form for use by local Boards of Health. Other forms naaybe'us� ' Rut thEe T
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 35 °" ��vW
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 n f f J-C `
Name ---
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
I C
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 If yes, was it cleaned? ❑ Yes K;? No
5. Observed condition of c mponen pumped:
6. System Pumped By,
0 � v��
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 Global Environmental, LLC, 20 So. Mill St., Bradford, MA 01835
Same day
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
�1 W City/Town of No. Andover JUN o 7 2022
�? System Pumping Record TCNVN 0 I,3�jTH ANDOVER
-- Form 4 HEAL;H 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, If��!/ �),f/C-„/� `.c,
use only the tab J �b
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 .
rerun
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 Elf o If yes, was it cleaned? ❑ Yes No
5. Observed condition of componentv �—'pumped:
6. System Pumped y:
Name Vehicle License Number
AS Development Corp. d/b/a
Stewart's Septic Service, 58 So. Kimball St.,
7. Location where contents were disposed:
Stewart's Global Environmental, LLC, 20 So. Mill St., Bradford, MA 01835
Same day
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
VjEDENED
Commonwealth of Massachusetts 2022
W City/Town of No. Andover
System Pumping Record -^ of:
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 No. Andover MA 01845
use the return Cityrrown State Zip Code
key.
2. System Owner:
Name - - - --- —
r�m
Address(if different from location)
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 B 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. Syste ed 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:
$,tsvirart's-Glob4 Environmental, LLC, 20 So. Mill St., Bradford, MA 01835
Same day
tSii
gnat uler Date
Same day
ature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
RECEIVED
Commonwealth of Massachusetts
W City/Town of No. Andover JUN p 7 2022
a System Pumping Record OF NOVA-TH ANDO\1ER
Form 4 SOHEALTH 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:
�n (
v
Name ---..- ----- -- —
�un
Address(if different from location)
CitylTown State Zip Code
_ Telephone Number
B. Pumping Record
Z-7 Z Z y'�
1. Date of Pumping - 2. Quantity Pumped: ���
Date Gallons
3. Component: ❑ Cesspool(s) ❑ Septic 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 com ent pumped:
6. S umped By:
/ A,) Oq
Na Vehicle License Number
J&S Development Corp. d/b/a
Stewart's Septic Service, 58 So. Kimball St.,
7. Location where contents were disposed:
Global Environ rrfal, LLC, 20 So. Mill St., Bradford, MA 01835
Same day
Sig at al Date
Same day
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11112 System Pumping Record•Page 1 of 1