Loading...
HomeMy WebLinkAboutSludge Tank - Septic Pumping Slip - 351 WILLOW STREET 11/3/2022 Commonwealth of Massachusetts RECEIVED W City/Town of No. Andover N�� p 3 202? System Pumping Record OF NORTH Form 4 TCHEALLTH DEPARTMENTEi ,^H H 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, Sq 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 ---- -- nun Address(if different from location) CitylTown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping I Ooc Z 2. Quantity Pumped: Datee Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap 131-�Other(describe): 4. Effluent Tee Filter present? ❑ Yes Lam"No If yes, was it cleaned? ❑ Yes ❑ No 5. Obs/e�e cfd ion of component pumped: 9Bd 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 J&S Development Corp. d/b/a Stewart's Septic 58 So. Kimball St., Bradford,MA 7. Location where contents were disposed: Stewarts Global Environmental, LLC, 20 So. Mill St., Bradford, MA 01835 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 Commonwealth of Massachusetts City/Town of No. Andover RECEIVE® System Pumping Record 2 Form 4 N�V p 3 202 / M F tJOBfH ANDOVER DEP has provided this form for use by local Boards of Health.`����pVffna,��%Id, but the information must be substantially the same as that provided here'.'Be 'ore 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��1/ 0 w 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: ,� J� Name ,mom 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): - v -- - 4. Effluent Tee Filter present? ❑ Yes I1_60 If yes, was it cleaned? ❑ Yes ❑ No 5. Observed ondition of component pumped: �e�n7 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 J&S Development Corp. d/b/a Stewart's Septic 58 So. Kimball St., Bradford,MA 7. Location where contents were disposed: Stewar'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 _ Commonwealth of Massachusetts City/Town of No.Andover RECEIVED System Pumping Record Form 4 NOV 3 2022 H ORTH ANDOVEF DEP has provided this form for use by local Boards of Health. Cymwa#y, 8, but the information must be substantially the same as that provided here. reusing 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 Wdadds cursor-do not 1-?A d ve K use the return City/Town State Zip Code key. 2. System Owner: !a6 Name Address(if different from location) No.Andover MA City/Town State Zip Code Telephone Number B. Pumping Record a 1. Date of Pumping Date Lf �� 2. Quantity Pumped: Gallons 3. 70ther nt: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap (describe): S�✓ �'� K 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped:nn 6—B d W-� 6. System Pumped . Name Vehicle License Number Stewart's Septic 58 So Kimball St. , Bradford,MA Company 7. Location where contents were disposed: 20 Sq.M il St.,Bradford,M vd, rf 4 �CK l L `/` Signature of Hau a 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 NOV 0 3 2o22 System Pumping Record TOWN OF NORTH ANDOVER ^M 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, ?�j �yr ri0 u 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: a Name - --- aem Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record r/�) 1 ��V C! 1. Date of Pumping DateG _ 22 - 2. Quantity Pumped: Gallons 3. Component: ❑ Cessp ol( ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): v 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed ndition of component pumped: r�o0 9 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 J&S Development Corp. d/b/a Stewart's Septic 58 So. Kimball St., Bradford,MA 7. Location where contents were disposed: StewaV I Global Environmental, LLC, 20 So. Mill St., Bradford, MA 01835 -,#,�_�f ___3 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 City/Town of No. Andover NOV 0 3 2022 System Pumping Record TOWN OF NORTH ANDOVER iG^M 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 No. Andover MA 01845 use the return City/Town State Zip Code key. 2. System Owner: f� 'A/ / J Name -— - ----- aN ietun Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Y Z 2. Quantity Pumped: �'3 ---— Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap S�d�-c- 40604.c ❑ Other(describe): - 4. Effluent Tee Filter present? ❑ Yes 91 No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. Syystteemc Pumped 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 Environmental, LLC, 20 So. Mill St., Bradford, MA 01835 �a-,&O-✓�_ 1 eS 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 NOV 0 3 2022 System Pumping Record TOWN OF NORTH ANDOVER Form 4 HEALTH 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, fA ' use only the tab �� key to move your Address cursor-do not No. Andover MA 01845 use the return key. City/Town State Zip Code 2. System Owner.- Name - — ieam Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1 ,) 1. Date of Pumping Date _2(_22 2 Quantity Pumped: Gallons w 3. ;Other pon nt: ❑ Cesspool(s) El Septic Tank ❑ Tight Tank ❑ Grease Trap (describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed c rndition of component pumped: 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: Stewart's Global Environmental, LLC, 20 So. Mill St., Bradford, MA 01835 '�K�' j -,t Same Signature of Haul r 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 RECEIVED = W City/Town of No. Andover NOV 0 3 2022 a System Pumping Record Form 4 TOWN OF NORTH ANDOVER wM 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 No. Andover MA 01845 use the return City/Town State Zip Code key. 2. System Owner: 0 Name dun 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 f 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 based on what he sees at time of pumping on the date above. 6. System Pumped 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 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 RECEIVED Commonwealth of Massachusetts City/Town of No. Andover Nov 0 3 2022 System Pumping Record TOWN OF NORTH ANDOVEH 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 - VV 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 --- - -- -- e(un 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 t-A If yes, was it cleaned? ❑ Yes;-�No 5. Observed condition of component pumpe : Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. System Pumped B C Nanle 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 Commonwealth of Massachusetts RECEIVED W City/Town of No. Andover System Pumping Record NOV 0 3 2022 Form 4 �M TOWN OF NORTH ANDOVEFi DEP has provided this form for use by local Boards of Health. Other for4 WPJ;g4W)%die 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, l I I W J 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:vl-±�i `�,� A c�+/� `✓�/ ` J Name seam 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 0 Other(describe): 4. Effluent Tee Filter present? ❑ Yes [�3'No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: qro -\ 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 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 �� �O�C' 5- 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