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HomeMy WebLinkAboutGrease Trap, Septic, Sludge - Septic Pumping Slip - 351 WILLOW STREET 2/6/2023 Commonwealth of Massachusetts RECEIVED W City/Town of No. Andover System Pumping Record Form 4 �M 5 ;•o�!�.�fr :40H"1"H ANDOVER DEP has provided this form for use by local Boards of Health. Other fol'm may �usecNbut 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 351 Willow Street key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. 2. System Owner: Bake 'N' Joy Name ✓arum Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record + �Z 1. Date of Pumping I— I 2. Quantity Pumped: — - Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): - 4. Effluent Tee Filter present? ❑ Yes Z No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: Sludge Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. System Pumped B 14 Truck# 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 ure 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 Form 4 TOWN OF NORTH ANDOVER M 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 -- 351 Willow Street -- key to move your Address cursor-do not No. Andover MA 018.45 use the return - -- key. City/Town State Zip Code 2. System Owner: r� Bake 'N' Joy Name -- - - renrn Address(if different from location) Citylrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2 3Date 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 ❑ No 5. Observed condition of component pumped: Sludge Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. SystePumped By: Q —Ge Truck# / 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 Glob vlronmental, LLC, 20 So. Mill St., Bradford, MA 01835 _ Same gna re of Hauler Date Same_ Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11112 System Pumping Record•Page 1 of 1 e Commonwealth of Massachusetts RECEIVED W City/Town of No. Andover System Pumping Record Form 4 TOWN OF NORTH ANDOVFR M 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 y Important:When filling out forms 1. System Location: on the computer, use only the tab 351 Willow Street key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. 2. System Owner: reb i Bake 'N' Joy Name — - --- - - r�m Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record ' 1. Date of Pumping -Date --� y 2. Quantity Pumped: Ga 0 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes R�No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: Sludge Observations are driver's opinion based on what he sees at time of pumping on the date above_ 6. System Pumped By: /,�la,s o 'n __ Truck# �'$3 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: StteewwJart'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 = W City/Town of No. Andover A System Pumping Record Form 4 TOWN OF+ `)r;TH ANDOVFi HEALTH s,EPARTMEN1T N 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 351 Willow Street 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� Bake 'N' Joy Name renm - -- - — --------------- Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 23 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 P"No If yes, was it cleaned? ❑ Yes ❑—Ko 5. Observed condition of component pumped: Sludge Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. System Pumped By: 0 G W f" k Truck# 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 � Commonwealth of Massachusetts RECEIVED W City/Town of No. Andover System Pumping Record Form 4 t r,rH ANaovER E,,? ' ',I\RTMENT 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 351 Willow Street key to move your Address cursor-do not No. Andover MA 01834 use the return --- - - ---- key. City/Town State Zip Code 2. System Owner: t� Bake W Joy__ _ Name ratan Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record , I,j 1. Date of Pumping --{— -� 2. Quantity Pumped. Date — Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): Sludge tanks 4. Effluent Tee Filter present? ❑ Yes ® No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: Sludge 6. Syste Pumped By: /� r Name Vehicle License Number Ste _ rt's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were disposed: 20 So. Mill St., Bradford, MA Same date 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 Commonwealth of Massachusetts RECEIVED - !& City/Town of No. Andover System Pumping Record Form 4 ' ANDOVFR 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 351 Willow Street key to move your Address cursor-do not No. Andover MA 01845 use the return -- key. CitylTown State Zip Code 2. System Owner: r� Bake 'N' Joy Name -- — - ---- rsnm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date Z7 Z3 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) eSeptic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): - -- 4. Effluent Tee Filter present? ❑ Yes L"o If yes, was it cleaned? ❑ Yes ®'No 5. Observed condition Qf c9mponent pumped: // , ftx'G 0 Sludge Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. System Pumped By: Truck# 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 RECEIVED Commonwealth of Massachusetts W City/Town of No. Andover FE3 p 2023 System Pumping Record ,;t•i J;NDOVF.R Form 4 ;, NARTMENT 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 "/),6 Wj S,'), 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_ Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe). 4. Effluent Tee Filter present? ❑ Yes E/No If yes, was it cleaned? ❑ Yes E�No 5. Observed Condit n of component pumped: 6. System Pumped By: 0 G Lh C-0 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•11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts RECEIVED w W City/Town of No. Andover vF p 6 2023 System Pumping Record r 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, use only the tab 351 Willow Street 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� Bake 'N'Name -- Name rim Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 23 2. Quantity Pumped: o Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes JNo If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: Sludge Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. System Pumped By: °�` -- - -- — Truck# - - - -- 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: Sttewart's Global Environmental, LLC, 20 So. Mill St., Bradford, MA 01835 /(/(`0-,50A -rdy&as - -- 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 r City/Town of No. Andover a System Pumping Record Form 4 TOWN OF NORTH ANDOVER w 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 351 Willow Street key to move your Address cursor-do not No. Andover _ MA 01845 use the return City/Town State Zip Code key. 2. System Owner: t� Bake 'N' Joy Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping pate - 2. Quantity Pumped: Gnso 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): — 4. Effluent Tee Filter present? ❑ Yes IiNo If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: Sludge Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. System Pumped By: 1111AS0V) Truck -- -- -- -----------.___-- 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: S,tee/wart'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 RECEIVED u . City/Town of No. Andover W° �� a 6 2023 System Pumping Record �- Form 4 TOWN OF NORTH ANDOVEFt bEAL_TH 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 351 Willow Street key to move your Address cursor-do not No. Andover MA 01845 _ use the return Cityrrown State Zip Code key. 2. System Owner: r� Bake Name - --- --- --- - _- --- renm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 3 2. Quantity Pumped: Gallons U 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ['S No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: Sludge Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. System/ Pumped By: Z�� 'q 5 tg V, Truck# 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 ,/�', �s d ::re✓) � CAS 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 Massachusettsif City/Town of No. Andover System Pumping Record TOWN OF NORTH ANDOVEH 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, use only the tab _ 351 Willow Street 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� -- -- -- - Bake 'N�— - Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date (C - 2. Quantity Pumped: Gauons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): - - 4. Effluent Tee Filter present? ❑ Yes'6d No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: Sludge Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. System Pumped By: (� Truck# y _ 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_ CSkj16-qjo6of 166er 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 4-r` ° System Pumping Record TOWN OF NORTH ANDOVER 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 computers/ use only the tab key to move your Address cursor-do not /_ 11?n �Qvre �� MA use the return key. City/Town State Zip Code 11 2. System Owner: tTame - ---_ renm 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 ED/No If yes, was it cleaned? ❑ Yes [31No 5. Observed condition of qomponent 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•11/12 System Pumping Record•Page 1 of 1 RECEIVED �L\ Commonwealth of Massachusetts City/Town of No. Andover 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, use only the tab 351 Willow Street key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. 2. System Owner: Bake 'N' Joy _ Name renm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping T3 73— 2. Quantity Pumped: Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes E No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: Sludge Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. System Pumped By: �cc) Truck# 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 ./614a.SQ 10 lanes 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 Commonwealth of Massachusetts RECEIVED w City/Town of No. Andover a System Pumping Record O-TOWN OFF 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, 351 Willow Street use only the tab key to move your Address 01845 cursor-do not No. Andover MA use the return Cityrrown State Zip Code key. 2. System Owner: t� Bake'N' Joy — Name -- — rertm --- Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record o 2. Quantity Pumped: Gallons 1. Date of Pumping Date 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): --- 4. Effluent Tee Filter present? ❑ Yes z No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: Sludge Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. System Pumped By: Truck# 33 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 I'la S 0 t� �C)Ae 5 Same Signature of Hauler Date Same Signature of Receiving Facility(or attach facility receipt) Date System Pumping Record•Page 1 of 1 t5form4.doc•11112