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HomeMy WebLinkAboutSludge Tank, Grease Trap, - Septic Pumping Slip - 351 WILLOW STREET 7/6/2022 RECEIVED Commonwealth of Massachusetts JUL 0 6 2022 city/Town of No.Andover TC'"j\J COr NORTH ANDOVER -- - System Pumping Record HEALTH DEPARTMENT r iY 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 Cityfrown 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 de 1. Date of Pumping Date 2• Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other (describe): Sf d c 6' �� 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed �j ndition of component pumped: C—,�hod` 6. Syystte Pumpe Ste% Name Vehicle License Number Stewart's Septic 58 So Kimball St. , Bradford,MA Company 7. Location where contents were disposed: 20 So.WI I St.,Bradford,MA igna ure of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1 RECEIVED ;,N.- Commonwealth of Massachusetts W City/Town of No. Andover JUL 0 6 2022 System Pumping Record ToV NG�;T t tiNDovER i-, H DEPARTMENT r` 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 use the return City/Town State Zip Code key. 2. System Owner: I,^ U� Name seem 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 Leo If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component p ed: Observations are driver's opinion ase on what he sees at time of pumping on the date above. 6. SystemTPed By: Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic 58 So. Kimball St., Bradford,MA 7. Location where contents were disposed:" jSign rt's Glo I Environ ntal, LLC, 20 So. Mill St., Bradford, MA 01835 Same of Date Same Signature of Re ing Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 RECEIVED Commonwealth of Massachusetts JUL. 0 6 2022 4 3 City/Town of No. Andover TOW' 1.W NORTH ANDCVER System Pumping Record HLiALTH DEPARTMENT 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 `►�CiLv ) - key to move your Address cursor-do not No. Andover MA use the return key. City/Town State Zip Code 2. System Owner: Name — Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 7 Z Z 2. Quantity Pumped: 0 V Date Gallons 3. :70theronent: ElCesspool(s) ❑ Septic Tank [:1Tight Tank ❑ Grease Trap (describe): 4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: coo Observations are driver's opinionNed on what he sees at time of pumping on the date above 6. Syste_jmped y: c `e_ A Name Vehicle License Number J&S Development Corp, d/b/a Stewart's Septic 58 So. Kimball St., Bradford MA 7. Location where contents were disposed: Stewart' nvironmental, LLC, 20 So. Mill St., Bradford, MA 01835 Same atur Hauler Date Same Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11112 System Pumping Record•Page 1 of 1 RECEIVED Commonwealth of Massachusetts a w City/Town of No. Andover JUL 0 6 2022 a System Pumping Record TOWN OF NORTH ANDOVER Form 4 HEALTH DEPARTMENT qM 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, 3,5-1 t111I0 0 use only the tab key to move your Address cursor-do not No. Andover MA use the return City/Town State Zip Code key. 2. System Owner: Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record /o - 1. Date of Pumping r 2� 2. Quantity Pumped: Date Gallons 3. Component: ElCesspool(s) ❑ Septic Tank ❑ Tight Tank Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component ed: "—t—A C/ Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. Syste " mped By: I �—�"— i, t" i( Name Vehicle License Number �"' J&S Development Corp. d/b/a Stewart's Septic 58 So. Kimball St., Bradford,MA 7. Location where contents were di sed: e art's Glob Environm al, LLC, 20 So. Mill St., Bradford, MA 01835 Same Sig atur aule Date Same Signature of ceiving 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 JUL 0 6 2022 System Pumping Record TO?�=iv OF NORTH ANDOVER 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, use only the tab key to move your Address cursor-do not use the return City/Town State Zip Code key. WORt2. System Owner: o � �l Name nam Address(if different from location) No.Andover MA City/Town State Zip Code Telephone Number B. Pumping Record coo 0 1. Date of Pumping oat hx/�—, 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank �x Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 44 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 RECEIVED Commonwealth of Massachusetts W City/Town of No. Andover Jul. 0 6 2022 System Pumping Record To'"N OF NORTH ANDOVER 0 t- ALTH DEPARTMENT Form 4 1y 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 CM 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, ) I'0 use only the tab ;t w key to move your Address cursor-do not No. Andover MA use the return City/Town State Zip Code key. 2. System Owner: � Name nom Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping - 1 ZZ 2. Quantity Pumped: Date allons 3. Component: ❑ Cesspool(s)D ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): 4. Effluent Tee Filter present? ❑ Yes 0 No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed co ition of component pumped: �fDil Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. System Pumped B Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic 58 So. Kimball St., Bradford,MA 7. Location where contents were disposed: Stewa to I EnvirfiAOmental, LLC, 20 So. Mill St., Bradford, MA 01835 ,( `f d Same (� ignature of Hauler Date Same 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 JUL 0 6 2022 System Pumping Record TCVUNOF NORTH ANDOVER r 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: f / ��- on the computer, use only the tab key to move your Address cursor-do not No. Andover MA 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 / 2. Quantity Pumped: -LJ Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank I rease Trap ❑ Other(describe): — 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component ed: r-,- (�'\ (�) W Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. Sy Pu�i1 ped By: r? Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic 58 So. Kimball St., Bradford,MA 7. Location where contents were dispose tew rt's Globa nvironm LC, 20 So. Mill St., Bradford, MA 01835 r Same Signature of Date Same Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11112 System Pumping Record•Page 1 of 1 RECEIVED Commonwealth of Massachusetts City/Town of No. Andover JUL 0 6 2022 NORTH System Pumping Record TOWN HEAO H DEPARTMENTER 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, r� use only the tab key to move your Address cursor-do not No. Andover MA use the return City/Town State Zip Code key. Of---1 2. System Owner: ��r 0 Name— ---- enm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping _ 6 23 —7i7/ 2. Quantity Pumped: ---- Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap sl Jc - �K Other(describe): - 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed ndition of component pumped: r, Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. ,S-ys�tem Pumped` Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic 58 So. Kimball St., Bradford,MA 7. Location where contents were disposed: Stewar' lobalJF4nvironmental, LLC, 20 So. Mill St., Bradford, MA 01835 Same � z -per - - S' a u Ha er Date Same Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11112 System Pumping Record•Page 1 of 1 RECEIVED Commonwealth of Massachusetts JUL 0 6 2022 W City/Town of No. Andover S stem Pum in Record TOWN OF NORTH ANDOVER Y p g HEALTH DEPARTMENT 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, 3s1 W n /- use only the tab JT key to move your Address cursor-do not No. Andover MA use the return key. City/Town State Zip Code 2. System Owner: VI �I L "A Jdv Name _ r�rm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping2. Quantity Pumped: Date Gallons 3. Component: ❑ Cesspool(s ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap sf�,��s�� ,e Other(describe): 4. Effluent Tee Filter present? ❑ Yes Vo If yes, was it cleaned? ❑ Yes ❑ No 5. Obs�ed coy�dition of component pumped: (��'�=may Observations are driver's opinion based on what he sees at time of pumping on the date above 6. System Pumped Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic 58 So. Kimball St., Bradford,MA 7. Location where contents were disposed: Stew 's Global nvironmental, LLC, 20 So. Mill St., Bradford, MA 01835 6 ` C ? �"—S Same �p �0� Signature of Hauler Date Same Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 RECEIVED Commonwealth of Massachusetts a1 W City/Town of No. Andover �u� 0 6 2022 'VN IR fH ANDOVER System Pumping Record = :i'-�.WTMENT iGM 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 use the return Cityrrown State Zip Code key. 2. System Owner: /�aI-e 'N ' Jo Name ream Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping ZZ-2. QuantityPumped:p g Date p Gallons 3. Component: ❑ Cesspool(s) ElSeptic Tank ❑ Tight Tank rease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes cl, O If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component ped: Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. Sy em mped By: ----7 Vrel,,� r--- ame Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic 58 So. Kimball St., Bradford,MA 7. Location where contents were Ste art's obal E onme tal C, 20 So. Mill St., Bradford, MA 01835 Same ture f auler Date Same Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1