HomeMy WebLinkAboutSeptic Tank, Sludge Tank, - Septic Pumping Slip - 351 WILLOW STREET 5/2/2023 RECEIVED
Commonwealth of Massachusetts
City/Town of No. Andover MAY 0 22023
W TOWN OF NORTH ANDOVER
System Pumping Record HEALT H DEPARTMENT
iG^M
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 01845
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 pate - -- 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 Kg-No
5. Observed condition of component pumped:
6-;;7
6. System Pumped By:
P 0 V0 .'G
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 MAY o 22023
W City/Town of No. Andover TOWN OF NORTH ANDOVER
System Pumping Record 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 01845
use the return City/Town State Zip Code
key.
e---I) 2. System Owner:
012L�i Bake'N' Joy
Name --- ----------
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 3 2. Quantity Pumped: 7.6D
Date Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
EZ(Other(describe): & V oe - —
4. Effluent Tee Filter present? ❑ Yes V/No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
vD
6. System Pumped By:
CF -
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bra_dford,MA
Company
7. Location where contents were disposed:
20 So. Mill St., Bradford, MA
,✓A' S-"A per as �-t
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 MAY 0 22023
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 01845
use the return City/Town State Zip Code
key.
2. System Owner:
t� Bake'N' Joy
Name
renrn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2 3 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
a—Other(describe): S l U C�q'<
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
LTUU�
6. Syst m Pumpe By:
Nam 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