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HomeMy WebLinkAboutGrease trap, Sludge tanks - Septic Pumping Slip - 351 WILLOW STREET 3/3/2023 ��CEIVEC� Commonwealth of Massachusetts City/Town of No. Andover System Pumping Record N0N ENS Form 4 �4"VAI"pE N lug 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 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 1. Date of Pumping 2. Quantity Pumped: Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Sludge tanks Other(describe): - — - --- 4. Effluent Tee Filter present? ❑ Yes ® No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: Sludge 6. Syste mped By: Name Vehicle License Number Stew s Septic 58 So. Kimball St., Bradford,MA CompaWy 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 RECOVED Commonwealth of Massachusetts = W City/Town of No. Andover MAR 0 3 2023 System Pumping Record TOWN OF NORTHANDOVER Form 4 HEALTH DEPARTMENT �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 01834 use the return key. City/Town State Zip Code 2. System Owner: t� Bake 'N' Jam— ---- - - Name ream Address(if different from location) City/Town State Zip Code -� Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: �6 G� 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. 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., Same date ignatur of Haul Date Same day Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 RECENED �L\ Commonwealth of Massachusetts W City/Town of No. Andover System Pumping Record T°HATM�P O"TEb x p Form 4 M A 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 City/Town State Zip Code key. 2. System Owner: t� Bake 'N' Job Name renm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date r T Z3 2. Quantity Pumped: Gall� s 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Sludge tanks Other(describe): -- 4. Effluent Tee Filter present? ❑ Yes ® No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: Sludge 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 Same date ature of er Date Same day _ Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 RECEIVED r Commonwealth of Massachusetts MAR 0 3 2023 a1 r� City/Town of No. Andover JI `` OF NOFiTH System Pumping Record TOWN HEALTH DEPARTM ANDOVER = v p 9 M ate ' 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 351 Willow Street key to move your Address cursor-do not No. Andover MA 01834 use the return City/Town State Zip Code key. 2. System Owner: r� Bake 'N' Jo Name rim Address(if different from location) City/Town State Zip Code Telephone(Number B. Pumping Record C 1. Date of Pumping Date 2 3 2. Quantity Pumped. 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. 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 Same date nature of lH ler Date Same day Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1 RECEIVED Ir Commonwealth of Massachusetts � : ; . : , City/Town of No. Andover ' W System Pumping 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, use only the tab 351 Willow Street key to move your Address cursor-do not No. Andover MA 01834 use the return Cityrrown State Zip Code key. 2. System Owner: Bake 'N' Joy _ Name return 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 ❑ Sludge tanks Other(describe): ---- - - 4. Effluent Tee Filter present? ❑ Yes ® No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed conditio,r of component pumped: L Sludge 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 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 RECEIVED 11�\_ Commonwealth of Massachusetts W City/Town of No. Andover ,DOVER System Pumping Record TOWN OF Now 2 Y p 9 HEALTH D�t't, ;ANT 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 351 Willow Street key to move your Address cursor-do not No. Andover MA 01834 use the return City/Town State Zip Code key. 2. System Owner: Bake'N' Joy Name - --- --- ream Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Z I Z3 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. S ste umped By: � � ;CIO------ 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 Same date a auler Date Same day _ 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 } System Pumping Record TOWN OF rv0111H 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 01834 use the return City/Town State Zip Code key. 2. System Owner: r� Bake 'N' Joy_ -- --..-- Name Address(if different from location) City/Town State Zip Code - — - Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: 0C1 o --- 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 off component pumped: ryC� Sludge 6. SysteKi Pumped By: T—N Name Vehicle License Number Stevdrts 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 N City/Town of No. Andover System Pumping Record 23 Form 4 " TOWN ND PARTMENFi TE 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 City/Town State Zip Code key. 2. System Owner: r� Bake 'N' Joy Name - - -- — ream Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping -- 2 �(� Z 3 2. Quantity Pumped: o o Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Sludge tanks Other(describe): -- 4. Effluent Tee Filter present? ❑ Yes ® No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: Sludge 6. System Pumped By: 7::5� I - Name Vehicle License Number Stewart's Septic 58 So. Kimball St., Brad_ford,M_A Company 7. Location where contents were disposed: 20 So. Mill St., Bradford, MA Same date i of er 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 70wN OF Nui�:n ANDOVEF °,M a HEAIX-I CtEPARTMENT 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: r� Bake 'N' Joy_- -- — -- Name -- - — -- —— -- —._—. ---— �n Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record moo heco 1. Date of Pumping r Z �,L 2. Quantity Pumped: 6/ l0( 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. System Pumped By: pS <3 Name Vehicle License Number Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were disposed: 20 So. ill St., Bradfo d, MA L f c \J Same date ignature of Hauler Date Same day Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11112 System Pumping Record•Page 1 of 1 BECOVED Commonwealth of Massachusetts H City/Town of No. Andover rAAR 3 2oL Z F System Pumping Record TONNN OF NO phi ANpO Form 4 NEAt-T"gFppRTMENT '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 use the return key. City/Town MA 01834 State Zip Code r� 2. System Owner: Bake 'N'Jo�r Name ---- renrn Address(if different from location) --- —_ _— City/Town State Zip Code Telephone Number B. Pumping Record - 1. Date of Pumping -- 'ZS' 2> y� Date 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank 9 ® Grease Trap ❑ Other(describe): Slu—d$e tanks 4. Effluent Tee Filter present? ❑ Yes [gll�o If yes, was it cleaned? � El Yes 2—No5. Observed Ud�ion of component pumped: Sludge 6. Sy tem Pumped By: if j\L, Name Stewart's Septic 58 So Kimball St., Bradford MA Vehicle License Number Company 7. Location where contents were disposed: 20 So. Mill St., Bradford, MA Signature of Hauler Same date Date Same day Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11112 System Pumping Record•Page 1 of 1 x-+ i n-� Ji 4fi' T!i_ - i