HomeMy WebLinkAboutSludge Tank, Septic Tank, Grease Trap - Septic Pumping Slip - 351 WILLOW STREET 8/3/2022 Commonwealth of Massachusetts
W City/Town of No. Andover ® �,
System Pumping Record ������
Form 4 tip'Lti
G Pc
DEP has provided this form for use by local Boards of Health. Other formspmay bpi kthe
information must be substantially the same as that provided here. Before � eck with your
local Board of Health to determine the form they use. The System Put �'br must be submitted to
the local Board of Health or other approving authority within 14 days from teepumo
ping 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 Cit /Town
key. y State Zip Code
�11 2. System Owner:
Name
ream
Address(if different from location)
City/Town State Zip Code
Telephone,Number
B. Pumping Record
1. Date of Pumping t Z?4— 2. Quantity Pumped: O V
Date Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
[Other(describe): `L'f
4. Effluent Tee Filter present? ❑ Yes 2 No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
Q004
Observations are driver's opinion ba on what he sees at time of pumping on the date above.
6. System Pum ed By:
Name � {
Vehicle License Number
AS Development Corp. d/b/a
Stewart's Septic 58 So. Kimball St., Bradford MA
7. Location where contents were disposed:
Stewart's Global Environmental, LLC, 20 So. Mill St., Bradford, MA 01835
_ Same
nat of Hauler Date
Same
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1
V�ECEIVElD
Commonwealth of Massachusetts A�6 p32o22
W City/Town of No. Andover
System Pumping Record
�oHLN��>afl�P���ME
iG^M
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 �yt
key to move your Address
cursor-do not No. Andover MA
use the return Cityrrown State Zip Code
key.
01_� 2. System Owner:
m ,/V T
Name
oy
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date ZZ 2. Quantity Pumped: Gallons 3H n c)
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:
Observations are driver's opinion ed on what he sees at time of pumping on the date above.
6. System Pumped B�
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 disposed:
Stewart's Global Environmental- ,-?0 So. Mill St., Bradford, MA 01835
Same
a of Hauler Date
Same
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11112 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of No. Andover
W° System Pumping Record �Ea
Form 4 �N PNoo
�M s ;,:�NDRpP�-AMEN
DEP has provided this form for use by local Boards of Heclo.11864, \Q fns may be used, but the
information must be substantially the same as that provided lcr-e. 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: I 1A)1
I
on the computer,
use only the tab _ __
SL
key to move your Address
cursor-do not NO. Andover MA
use the return Cityfrown State Zip Code
key.
2. System Owner: �
J
Name — ---- --
npa
Address(if different from location)
Cityfrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date ' Zv 2_ Quantity Pumped: Gallons�C
3. Component: ❑ Cesspool(s ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑ Yes to If yes, was it cleaned? ❑ Yes ❑ No
5. O79r—
b erved 7dition of component pumped:
t)(j
Observations.are driver's opinion based on what he sees at time of pumping on the date above.
6. System Pumped By:
Name Vehicle License Number
AS Development Corp. d/b/a
Stewart's Septic 58 So. Kimball St., Bradford,MA
7. Location where contents were disposed:
StewaoI Global Eqvironmental, LLC, 20 So. Mill St., Bradford, MA 018�335zl
\,./ Same
Signature of Hauler Date
Same
Signature of Receiving Facility(or attach facility receipt) Date
t5forrn4.doc•11112 System Pumping Record•Page 1 of 1
,EScewEp
Commonwealth of Massachusetts o 3 IV
City/Town of No. Andover WG opvER
System Pumping Record ►o�Npv`J� MEW
Form 4 p g Tp HEP.-TH DE?AR
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, ,5 W(61,) S�
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:
'/V N&A1
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record 43o�D
1. Date of Pumping Date _ 2 2. Quantity Pumped: Gaifons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
(Other(describe): "
4. Effluent Tee Filter present? ❑ Yes 25No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
a
Observations are driver's opini(n ased on what he sees at time of pumping on the date above.
6. System P ped 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:
Stewart's Global ental, LLC, 20 So. Mill St., Bradford, MA 01835
�i Same
na of Haul Date
Same
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
DECEIVED
�L\ Commonwealth of Massachusetts uG 3 2022
W City/Town of No. Andover A
a System Pumping Record TOWN c�NoRTH TN DE�'A�TMENT R
Form 4
H�hL
'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, �51 w( S� (ill ,VGJ
1
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:
ICI Name
rrm
Address(if different from location)
City/Town State Zip Code
_ Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: oil
Date Gallons
3. Compon nt: ❑ Cesspool(s) El Septic Tank ❑ Tight Tank El Grease Trap
Other(describe): `�
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Ob7:1_�_
ed ction of component pumped:
o I
Observations are driver's opinion based on what he sees at time of pumping on the date above.
6. Sys el Pumped B f
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 's Global E vironme( I, LLC, 20 So. Mill St., Bradford, MA 01835
u \J ('��`-S Same � c �` c�7,
tl 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
�4ECEkvEG
Commonwealth of Massachusetts AUG 3la,
City/Town of No. Andover NoovEa
a System Pumping Record �c NTH°AFAR "ENT
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, Z t; t� /,I've
use only the tab VV
_ l/
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
rab f ,
ti �jo
Name
nbn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 22- ZZ 2. Quantity Pumped: ��`
Date Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe): `!�;` v `�'C� ✓—��
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed cond� ion of component pumped:
<9-0
Observations are driver's opinion based on what he sees at time of pumping on the date above.
6. Sys a Pumped By:
, U'l
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:
Stewags Global Environmental, LLC, 20 So. Mill St., Bradford, MA 01835
a C Same
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
W City/Town of No. Andover AUG p 3 2022
System Pumping Record oR�HANDo\JER
Form 4 -TOWN OF DE?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, �W I i, ,��fo )
use only the tab �J1/ /
key to move your Address
cursor-do not No. Andover MA 01845
use the return
key. City/Town State Zip Code
�1 2. System Owner:
V� P 'Al Crxe w
Name
nem
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) [R'Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Cq-�o If yes, was it cleaned? ❑ Yes E4—No
5. Observed conditio of com o ent pumped:
Observations are driver's opinion based on what he sees at time of pumping on the date above
6. Systp`Pumpe �
Name 1(/%� Vehicle License Number
AS Development Corp. d/b/a
Stewart's Septic 58 So. Kimball St., Bradford,MA
7. Location where contents were disposed:
Stewart's Global Environmental, LLC, 20 So. Mill St., Bradford, MA 01835
Same
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
�LN Commonwealth of Massachusetts
N ( City/Town of No. Andover 2022
System Pumping Record AEG 3 vE�
Form 4 SOWN OF Np�Ppps M O
HEP�jH
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 15-1
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 -- --
ieem
Address(if different from location)
Cityfrown State Zip Code
Telephone Number
B. Pumping Record 1) 0"
1. Date of Pumping - �— 2 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -
4. Effluent Tee Filter present? ❑ Yes 5;�/No If yes, was it cleaned? ❑ Yes ❑�id6�
5. Observed condition of component urn ed:
Observations are driver's opinion based on what he sees at time of pumping on the date above.
6. System Pumped By:
��/ /
VQ
Name C/ 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's Global Environmental, LLC, 20 So. Mill St., Bradford, MA 01835
Same _
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
RE 014ev
Commonwealth of Massachusetts o3�022
W City/Town of No. Andover p�G o�Ea
System Pumping Record
a
oFNo��Pa"°EN�
Form 4 �O"eo-.�N�EP
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 W
key to move your Address
cursor-do not No. Andover MA 01845
use the return Cityrrown State Zip Code
key.
2. System Owner: _
A,
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 j Grease Trap
❑ Other(describe): L J
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped: ca—�
Observations are driver's opinion based on whathhe sees at time of pumping on the date above.
6. System Pumped By/:-�
�% u 3A 0C
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's Global Environmental, LLC, 20 So. Mill St., Bradford, MA 01835
Same
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