Loading...
HomeMy WebLinkAboutSludge Tank - Septic Pumping Slip - 351 WILLOW STREET 5/2/2023 Commonwealth of Massachusetts RECEIVED 4 W City/Town of No. Andover System Pumping Record VAY o 22023 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 01845 use the return key. City/Town State Zip Code 2. System Owner: tb Bake'N' Joy 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 cRq-0ther(describe): 45 4. Effluent Tee Filter present? ❑ Yes(Q No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: G©c C� 6. System Pumped By: x� �on� 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 RECEIVEC) City/Town of No. Andover System Pumping Record Form 4 TOWN OF NOATti N00 M HEALTH®E'er TMENT 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' Job- -- -__ . - — — --- --- 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 2'lNo If yes, was it cleaned? ❑ Yes D-to 5. Observed condition of componen umped: 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 Commonwealth of Massachusetts f^r;Y 4 2 2023 W City/Town of No. Andover System Pumping Record TOWN HEALTH DEPARTM NTJORTH EtS 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 Name- — — Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record �Z 1. Date of Pumping Date 2. Quantity Pumped: Gallo0Uv 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): S�" 11 5�. J�"/-- 4. Effluent Tee Filter present? ❑ Yes n No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: �0C --- 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, M& lop 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 City/Town of No. Andover ;_;� System Pumping Record � J Form 4 TOWN LLTH DEPARTMENT OF NORTH ER 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 --- --- Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record �F-z(- 23 L>"7-0 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• 11112 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts RECEIVED City/Town of No. Andover System Pumping Record p'pY o 2023 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 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 1. Date of Pumping Date — L1 '�3 2. Quantity Pumped: Galfons� 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap [Other(describe): `� U 4()C 4. Effluent Tee Filter present? ❑ Yes 2/No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: gay 6. System Pumped By: CL 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 /y �CaS., joy.eS L4l Y-t o 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 frhY 022023 System Pumping Record TOWN OF NORTH ANDOVU 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 key. City/Town State Zip Code 2. System Owner: r� Bake'N' Joy _ Name - -- - - - r�m Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record L4- l -Zaa 1. Date of Pumping Date _ 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank El Tight Tank ❑ Grease Trap � Other(describe): ��lfe, 4-ot A,LL- 4. Effluent Tee Filter present? ❑ Yes 2/No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of co ponent pumped: 00 6. System Pumped By: Al aS0n 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 /40- nag 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 0 RECEIVED w W City/Town of No. Andover MAY 0 22023 System Pumping Record TOWN OF NORTHANDOVE" r` 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 key. City/Town State Zip Code 2. System Owner: t� Bake'N' Job Name - - �un Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date _f 4 rZ 3 2. Quantity Pumped. �U 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): 4. Effluent Tee Filter present? ❑ Yes �L No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: S;'Q QC 6. System Pumped Bf 4_ U o Name Vehicle License Number Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were disposed: 20 S . Mill St., Bradford, M 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 log W City/Town of No. Andover o�2023 W° System Pumping Record Piny Form 4 ?OWN OF NORTH ANDS T5R HEALTH DEPARjM 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: r� Bake'N' Joy _ Name ,mom Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record ?j y 1. Date of Pumping Date I Z3 2. Quantity Pumped: Gallo 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank El Grease Trap ❑ Other(describe): `S�`��� -2 `7��/z -- 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 6. Syste umped By: Nam Vehicle License Number Ste art'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 Yr_Ur_1VCL/ Commonwealth of Massachusetts MAY 022023 City/Town of No. Andover TOWN OF NORTH ANDOVEI System Pumping Record HEALTH DEPARTMENT Form 4 1 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: V� Bake'N' Joy Name — ienm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Dater _ f I ' Z �— 2. Quantity Pumped. IIons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap [✓]Other(describe): SI U � 4. Effluent Tee Filter present? ❑ Yes En-"N o If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 6. System By: 1 Name Vehicle License Number Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were disposed: 20 So. Mill St., dford, MA gnature of H Date Same day Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1