Loading...
HomeMy WebLinkAboutGrease, Sludge Tank, Septic Tank - Septic Pumping Slip - 351 WILLOW STREET 4/3/2023 RECEIVED Commonwealth of Massachusetts W City/Town of No. Andover System Pumping Record i` )Wq OF Nuys tH 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' Joy Name - 2dm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record *3,00 d 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 No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component 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 i _ _ __ T � _ _ _ _ __ __ _ _ AECENED _ Commonwealth of Massachusetts W City/Town of No. Andover a System Pumping Record T�"�'�'a� a pH TMEN E y p g HL=ALTH �pARMENT 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 01845 use the return City/Town State Zip Code key. 2. System Owner: r� Bake 'N' Joy Name renen 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 No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed con ition of component 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. ill St., Bradford, MA— Signature of Hauler Date Same day Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11112 System Pumping Record•Page 1 of 1 i Commonwealth of Massachusetts RECEIVE[) W City/Town of No. Andover W° System Pumping Record Form 4 GSM , 1 OWN OF NORTH H ANDOVEti 4; A!.T4,rEp 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 01845 use the return key. City/Town State Zip Code 2. System Owner: f� 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:Date 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 co onent pumped: L 6. System Pumped By: P e�� 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 Commonwealth of Massachusetts W City/Town of No. Andover System Pumping Record TOWN OFNC'i,HANDOVE�A Form 4 HEALTH DEPARTNAENT 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: t� Bake 'N' Joy Name - -- Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record //11 1. Date of Pumping �lZ��23 2. Quantity Pumped: — Date 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 pump 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. radforcf, MA �P p�3 Si f H uler Dam 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 HECEIVELI: _ City/Town of No. Andover N a System Pumping Record Form 4 TOWN OF NORTH ANDOVEk 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 01845 use the return City/Town State Zip Code key. 2. System Owner: r� Bake 'N' Joy Name -- — iemm 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) E� 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 condi qon of cooponent 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• 11112 System Pumping Record•Page 1 of 1 HL(;L.IVI t> Commonwealth of Massachusetts u W City/Town of No. Andover System Pumping Record roWN of NORTH ANDovEk 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 fo 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 - ------_..._ rel+dn 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): 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 Pump! Q 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 HECEIVEU Commonwealth of Massachusetts City/Town of No. Andover 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 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 - -- - - -- - -- - --_ -- -- renm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping — 2. Q y, Date uantity 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 condition of component pumped: 6 a u'-, Sludge 6. Syste W ed By: A, 1_L_ — Name Vehicle License Number Ste '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 ViECENED Commonwealth of Massachusetts City/Town of No. Andover Ek System Pumping Record fCwN of NORTH ANDGT r o Form 4 HEALTH CEPARTMENT 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: r� Bake 'N' Joy Name— -- --- --- - ---- - — — renm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record "?goo 1. Date of Pumping +Date Gallons 2. Quantity Pumped: - 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 Pu ed 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 Hauler Date _ Same day Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11112 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts RECEIVEL) .1City/Town of No. Andover ° System Pumping Record Form 4 TOWN OF NORTH ANDOVEI=i 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 key. CityrTown State Zip Code 2. System Owner: Bake'N' Joy Name �etun 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 condition of component pumped: Sludge 6. System Pumped By: Name Vehicle License Number Stewart's Septic 58 So. Kimball St., B_radf_ord_,_MA Company 7. Location where contents were disposed: 20 So. Mill St., Bradford, MA _ Same date i 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 rtECENED '�Z\ Commonwealth of Massachusetts W City/Town of No. Andover System Pumping Record Ov R-�HANoovt� Form 4 toHEALTH 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 01834 use the return - -- - key. City/Town State Zip Code �1 2. System Owner: V� Bake 'N' Joy Name -- — - - - repro Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record t�?3 3,oe�o 1. Date of Pumping Date 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: 141a (�,,j Name Gam— Vehicle License Number Stewart's Septic 58 So. Kimball St., Bradfo_rd,MA Company 7. Location where contents were disposed: 20 So. Mill St., Bradford, MA Q6 r _ Same date_ Signature of Hauler Date Same day Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11112 System Pumping Record•Page 1 of 1 s�tGElVtI% �LN Commonwealth of Massachusetts City/Town of No. Andover System Pumping Record OVE Form 4 I OWN OF Noll AN ,M HEALTH DEPAPTM�-NT 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 -- --------- ---- rettrm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Dat d Z 2. Quantity Pumped: G�coc) ns 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: A a-$O)q - 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 a SCj-A _To Y\OS 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 RECEw_0 H W City/Town of No. Andover W° System Pumping Record ';23 Form 4 F NORTH ANDOVER ,M TOLE�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 01834 use the return City/Town State Zip Code key. 2. System Owner: t� Bake'N' Joy Name ratan Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping ✓2� 2. Quantity Pumped: Datee 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: Jet Name Vehicle License Number Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were disposed: 20 So. MP St., B Same date S' ature 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 'C'*\ Commonwealth of Massachusetts ,jECENED W City/Town of No. Andover p23 System Pumping Record APR Ci3HANDOVER Form 4 T HE�TH 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, use only the tab I 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' Joy Name -- - m�ren Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date , ^ J 2. Quantity Pumped: Gallons O 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, MA 141QqL_,, -_-fO<`eS 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 If I Commonwealth of Massachusetts ,jECE�vECp City/Town of No. Andover System Pumping Record Form 4 OF NORTH ANpO\'ER TOWN 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 '3 __' Z 3 -- 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. System Pumped By: micas C'�q 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 xa��l��S 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