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HomeMy WebLinkAboutSeptic Tank, sludge tank, Grease Trap, - Septic Pumping Slip - 351 WILLOW STREET 8/4/2023 -C-\ Commonwealth of Massachusetts �e City/Town of No. Andover System Pumping Record 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 key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. do h Z. System Owner. l 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) 12 Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ffr<o 5. Observed condition of cinponent pumped: 6. System Pumped By: 7) � �pC,V,Ic 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 System Pumping Record•Page 1 of 1 t5form4.doc•11/12 Commonwealth of Massachusetts 10-% M City/Town of No. Andover M System Pumping Record a 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, 351 use only the tab 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 �nr Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2 2. Quantity Pumped: CP-4 Date Gallons 3. Compon ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): z/ `f4--�� 4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No 5. Obse rved ndition of component pumped: 6. System Pumpe Name Vehicle License Number Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were disposed: 20 So.Mill St., Bradfo , MA I-ISig ture o auler Date Same day Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11112 System Pumping Record•Page 1 of 1 �LN Commonwealth of Massachusetts a W City/Town of No. Andover System Pumping Record Form 4 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, I LJG use only the tab _ I 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 k ,N , J Name renen Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumpingz� �3 2. Quantity Pumped: �G Date Gallons 3. Component: ❑ Cesspool(s) C❑ Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe). "(V �qe 4. Effluent Tee Filter present? ❑ Yes [�J/No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 6. System Pumped By: /'4CLScs n 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 µ City/Town of No. Andover o�tio't o System Pumping Record ` 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 Ming out forms 1. System Location: on the computer, use only the tab ,jam W •�/ key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. 2. System Owner: aC) Name rertm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping �—ZZ—� 2. Quantity Pumped: Gallons Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank Z--Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes P 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 Gay Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11112 System Pumping Record•Page 1 of 1 IL Commonwealth of Massachusetts W City/Town of No. Andover System Pumping Record p 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 5 I "-y o i, key to move your Address cursor-do not No. Andover _ MA 01845 use the return City/Town State Zip Code key. t� 2. System Owner: Name - -_ ream Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping pa 3 — 2. Quantity Pumped: Gallons U 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., BTzdord, MA ig ur 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-N Commonwealth of Massachusetts A�'L, a City/Town of No. Andover Oro System Pumping Record 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 key to move your Address cursor-do not No. Andover MA 01845 use the return CityfTown State Zip Code key. 2. System Owner: Name — 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) [f Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes LR' No If yes, was it cleaned? ❑ Yes (]1No 5. Observed condition of componen 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 _ City/Town of No. Andover M a W° System Pumping Record 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 �/ � � 14�✓ J t key to move your Address cursor-do not No. Andover MA 01845 _ use the return City/Town State Zip Code key. 2. System Owner: Jo Name Address(if different from location) Cityfrown State Zip Code Telephone Number B. Pumping Record �1 C3G�� 1. Date of Pumping I ( 2-32. Quantity Pumped: ���0 � 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 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 came day Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11112 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of No. Andover 61, System Pumping Record 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: Bake 'N' Job Name idrm 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 Cd No If yes, was it cleaned? ❑ Yes�No 5. Observed conditio of component pumped: 6. Sy m Pumped By: Name Vehicle License Number Stewart's Septic 58 So. Kimball St., Bradf_ord,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 rG� Commonwealth of Massachusetts City/Town of No. Andover a System Pumping Record 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 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 � 1J Name !Eld/ll t:' Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record _��o _ 1. Date of Pumping Date �f�—� 2. Quantity Pumped: � ns � 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap , dOther(describe): s k lj 4a �Q-Y XC' 4. Effluent Tee Filter present? ❑ Yes Lid No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: Qoa 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 Mauler Date Same day Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11112 System Pumping Record•Page 1 of 1 ` �L\ Commonwealth of Massachusetts City/Town of No. Andover io a W° System Pumping Record A��,Oj� y` Form 4 M y+ 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 key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. �11 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. Compon nt: ElCesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap ) f Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed cg,dition of component pumped: CI�J 6. System Pped 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 G aL, 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 o�tio�o City/Town of No. Andover W° System Pumping Record 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: V on the computer, �� use only the tab key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. f� 2. System Owner: t/V t ZU Name renm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: CJ Date Gall 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap �ther(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed ndition of component pumped: Gd6f� 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, 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 - City/Town of m - ( System Pumping Record 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: 1 on the computer, I 1 i (�( , use only the tab w V� I key to move your Address cursor-do not J\, �� MA use the return City/Town State Zip Code key. 2. System Owner: Same k42 A/ Name — Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record /� 1. Date of Pumping Date 2. Quantity Pumped: �a�so v — 9 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap R Other(describe): -- -S) ud-w *0 A — 4. Effluent Tee Filter present? ❑ Yes ET/No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped:_SjU4V_ All of this estimated information is non-binding, valid only at the time pumping. Not responsible beyond the date above. 6. System Pumped By: Name Vehicle License Number Company 7. Location where contents were disposed: Stewart's Receiving Fa.Cility, 20 So. Mill St., Bradford, MA \ See above natu Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts H City/Town of No. Andover 04,�023 System Pumping Record p,�G Form 4 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 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 2 1. Date of Pumping at �� 2. Quantity Pumped: Date Gallons ns 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap $' Other(describe): - S 1 b A 3 --- 4. Effluent Tee Filter present? ❑ Yes E�/No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 940 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