The URL can be used to link to this page

Home My WebLink AboutSludge Tank, Septic Tank - Septic Pumping Slip - 351 WILLOW STREET 12/5/2022 Commonwealth of Massachusetts W City/Town of No. Andover ` System Pumping Record DEC 0 5 2022 ^M Sv Form 4 TOWN OF NORTH ANDOVER 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 Cityrrown State Zip Code key. 2. System Owner: eat& r� T Name -- ienm 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. :;7 pto nt: ❑ Cesspool(ss) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Oher(describe): `��`�� v� l 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed c dition of component pumped: de er- Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. System Pumped By: \'j e-5 GC91 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: Stewa 's Global En ironmental LLC, 20 So. Mill St., Bradford, MA 01835 �� Same ��--- Signature of Hau er 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 ew R� W City/Town of No. Andover a System Pumping Record DEC 0 5 2022 Form 4 TOWN OF NORTH ANDOVER 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, R use only the tab 7`f I key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. p t� 2. System Owner: ^1 Name rerun Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date( J ZZ 2. Quantity Pumped: Ga lon(s Oc) 3. Component: ❑ Cesspool(s) ] El 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: O Observations are driver's opinion based what he sees at time of pumping on the date above. 6. System Pumped By: al'Cg 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 ature of Hauler Date Same Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1 t IRECEIVED Commonwealth of Massachusetts DEC 0 5 2022 City/Town of No. Andover ° System Pumping Record TOWN OF NORTHANDOVER Form 4 HEALTH DEPARTMENT�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, 7/ ��((0 vi Sf 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 �aam Address(if different from location) City/Town State Zip Code T6lephone Number B. Pumping Record U 1. Date of Pumping Date (( I 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s)- ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): 4. Effluent Tee Filter present? ❑ Yes [D-lo If yes, was it cleaned? ❑ Yes ❑ No 5. Observed ndition of component pumped: 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: yStewa.'s GI bal Environmental, LLC, 20 So. Mill St., Bradford,, MA 01835 G e4d d-7 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 RF-CENED Commonwealth of Massachusetts W City/Town of No. AndoverOVEFt DEC 0 5 2022 System Pumping Record ;OFNOR'TH AND NT t._ALTH DEPARTME Form 4NT �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 y 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: / - y r� &&, 1 Name �J rotun Address(if different from location) City/Town State Zip Code Tolephone Number B. Pumping Record yy 1. Date of Pumping Date 2. Quantity Pumped:p Gallons 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 based on what he see at time of pumping on the date above. 6. System Pumped By: /V1 c� 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•11112 System Pumping Record•Page 1 of 1 �" RECFN�a Commonwealth of Massachusetts W City/Town of No. Andover DEC 0 5 2022 System Pumping Record 'r.-*' oFNOT CHANDOVER Form 4 311ALTH DEPARTMENT wM 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, tow 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 Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2 2. Quantity Pumped: Gallons 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 E 1 No 5. Observed condition of component pum ed: Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. System Pumped By: P ( /hr—h.` L 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 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 City/Town of No. Andover DEC o 5 2022 System Pumping Record TOWN 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, 3�� Vy f��y 1�v S� NeW 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: t� J� ► r Name anm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Dal I' 2. Quantity Pumped: Gall 0 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): � - � N 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 Nsj on what he sees at time of pumping on the date above. 6. System Pumped By: 'n�- 9 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 E vironmental, LLC, 20 So. Mill St., Bradford, MA 01835 Same atur o er Date Same Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 Commonwealth of assachusetts RECEIVED -- - City/Town of 2022 System Pumping Record Form 4 TOWN aF WORTH AraDovE HEALTH 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, use only the tab key to move your Address cursor-do not use the return key. City/Town State Zip Code 2. System Owner: .-- ra� Name 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:p ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank �,Gr ❑ Other(describe): 4. Effluent Tee Filter present? JrYes ❑ No If yes, was it cleaned? Yes ❑ No 5. Observed condition of pomponent pumped: 6. System z ped y: Q� �O Name Vehicle License Number Stewatt'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 Commonweal of Massachusetts RECEIVED = City/Town of �c;;;��_ A DEC 0 5 2022 a System Pumping Record Form 4 TOWN OF NORTH ANDOVER 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 G key to move your Address cursor-do not MA use the return City/Town State Zip Code Y 2. System Owner: �— t� � Name ern 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? �es ❑ No If yes, was it cleaned? Yes ❑ No 5. Observed condition of component pumped: Observations are driver's opi based on what he sees at time of pumping on the date above. 6. Sy5kem 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•11112 System Pumping Record•Page 1 of 1 ,C",\ Commonwealth of Massachusetts W City/Town of No. Andover W° System Pumping Record DEC 0 5 2022 Form 4 TOWN OF NOSTH ANDOVER " HEALTH VEPARTMENT 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 7! 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 reasn Address(if different from location) City/Town State Zip Code Telephone N::mber _B. Pumping Record 1. Date of Pumping iqzz�Date 2. Quantity Pumped: Gallons 3. Compo ent: ❑ CCesssppool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): '— )I/ 4. Effluent Tee Filter present? ❑ Yes to If yes, was it cleaned? ❑ Yes ❑ No 5. Observed con Ion of component pumped: Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. System Pumpedi 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' Global Environme/n , LLC, 20 So. Mill St., Bradford, MA 01835 `S Same zignatKure 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 City/Town of No. Andover System Pumping Record .` Form 4 " TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. Other forAS", ba d�'e ,'Ri 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: /n/( � on the computer, V V use only the tab key to move your Address cursor-do not No. Andover use the return MA 01845 key. City/Town State Zip Code 2. System Owner: �� /A// Torab /V Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping I ZZ 2. Quantity Pumped: ;ZW 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 ❑ No 5. Observed c dition 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 AS Development Corp. d/b/a Stewart's Septic 58 So. Kimball St., Bradford,MA 7. Location where contents were disposed: Stews 's Global EnvironmWel, 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 City/Town of No. Andover ° System Pumping Record TOWN OF NORTH AND OVER Form4 HEALTH DEPARTMENT �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 tt 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��l Z ot�c Name /v ream Address(if different from location) City/Town State Zip Code - -- -- - Telephone l!m er B. Pumping Record 1. Date of Pumping Date I Z� Z 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s El Septic Tank ❑ Tight Tank [I Grease Trap '51 u° Cyr , a•'�� Other(describe): 4. Effluent Tee Filter present? ❑ Yes LAY No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed ondition of component pumped: &-OVC� Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. System Pumpe 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: Stew 's Global Environmental, LLC, 20 So. Mill St., Bradford, MA 01835 -s:y- Same 11 _ �'� '2 jSigZ—nat—,rLeofr Date Same Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1