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HomeMy WebLinkAboutSludge, Tigh Tank, Grease Trap, - Septic Pumping Slip - 351 WILLOW STREET 9/5/2023 1�:N Commonwealth of Massachusetts W City/Town of No. Andover OStio W° System Pumping Record Sip 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 7 Uv J key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. y� 2. System Owner: Name -- --- -- n� Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping pate , 3 2. Quantity Pumped: Gallons 3. Compo ent: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap ��CU� Other(describe): 4. Effluent Tee Filter present? ❑ Yes Z&-No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed c ndition 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 S . 111 St., Bradford, M eW ��Jc,�' C:�� 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 W City/Town of No. Andover System Pumping Record 5 2023 Form 4 So ' 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, I , 4ai ,�/ — use only the tab ;7 (f�/ key to move your Address cursor-do not No. Andover use the return Cit /Town MA 01845 key. State Zip Code 2. System Owner: �- - ,Name foil rensn Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record- 1, Date of Pumping o I 2. Quantity Pumped: Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank VTight Tank ❑ Grease Trap ❑ Other(describe): --- 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes-Efr-No 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• 11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts W City/Town of No. Andover W° System Pumping Record SEP p 51013 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, ', I /! use only the tab W, f 1 0 yi Yf key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. 2. System Owner: rab I J N I a Name rum 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 ther(describe): 4. Effluent Tee Filter present? ❑ Yes to If yes, was it cleaned? ❑ Yes ❑ No 5. Observed ndition of component pumped: 6. System Pumped By !2 y Name Vehicle License Number Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were disposed: 20 So. MM St. Bradford, MA Signat re of Kauler 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 u W City/Town of No. Andover System Pumping Record SEp 052023 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,/ pew use only the tab �/ I /v 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 renen Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record �\ 1. Date of Pumping Date 22 ^ 2. Quantity Pumped: Gallons c� " 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 Commonwealth of Massachusetts City/Town of No.Andover Q b51b3 System Pumping Record SE 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, r/V ` t / use only the tab / key to move your ,Addre s �� cursor-do not v UN use the return City/Town f� State Zip Code key. 2. System Owner: �,Iu Y6, ,/V'- `J0 Name Henan Address(if different from location) No.Andover MA City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date te< 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): 4. Effluent Tee Filter present? ❑ Yes VJ-No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 6. System Pumped '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 Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 �LN Commonwealth of Massachusetts W City/Town of No. Andover System Pumping Record Q ©5 tio'L3 Form 4 SE 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 35/ ,/(6 W/ key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. r� 2. System Owner: N . c) 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 C 3. C�Other t: ❑ Cesspool(s ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap t describe): - 4. Effluent Tee Filter present? ❑ Yes U—No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed,condition of component pumped: �_0) 6. System Pumped P!;/ owe ' Name Vehicle License Number Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were disposed: 20 5o.Aill St., Br dford, MA Si nature of Hatifer Date Same day Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1 �L\ Commonwealth of Massachusetts _ City/Town of No. Andover System Pumping Record SEP 0 5 2023 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, //O s use only the tab I 'V I key to move your Address cursor-do not No. Andover MA 01845 use the return CityfTown State Zip Code key. 2. System Owner: n/ Jo Name nrs Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date Z� 2. Quantity Pumped: GallonsG C 3. Component: ❑ Cesspool(s) ❑ Septic Tank El Tight Tank El Grease Trap Other(describe): `S!v --? 4. Effluent Tee Filter present? ❑ Yes ®--No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: (5r-'00 U 6. System Pumpe�: rName Vehicle License Number Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were disposed: y20So20 So ill St., Bradford, M Signature o Hauler Date dame day Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11112 System Pumping Record•Page 1 of 1 � Commonwealth ea th of Massachusetts u W City/Town of No. Andover Q oc,'Lo System Pumping Record S� 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, -61 r� 1/Cow J 1'— 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: �N f Name rim Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record O / 1. Date of Pumping o I S Z 2. Quantity Pumped: c�0a Date Gallons 3. Compone ElCesspool(s) ❑ Septic Tank El Tight Tank ❑ Grease Trap ther(describe): �'SI V d5c - - 4. Effluent Tee Filter present? ❑ Yes Oa_Ns If yes, was it cleaned? ❑ Yes ❑ No 5. Observe dition of component pumped: Observed 6. System Pumped 'f U' �7 S _ 3 Name Vehicle License Number Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were disposed: 20 So. MjKSt., Bradfo d, 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 N� Commonwealth of Massachusetts ��pPR�M✓ City/Town of No. Andover �E��-�N e o5tioti3 System Pumping Record SE ` 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 Cityfrown State Zip Code key. 2. System Owner: Jov Name ream Address(if different from location) CityfTown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Datef ( (7-3 2. Quantity Pumped: Gallons 3. Compon t: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): S"""'L� 4. Effluent Tee Filter present? ❑ Yes O—No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed c ndition of component pumped: 6. System Pumped ee_-_ �Ucy__e� Name Vehicle License Number Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were disposed: 20 So. W1 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 'C"\ Commonwealth of Massachusetts P�' �✓�� L City/Town of No. Andover 3 System Pumping Recordo�tioti 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, l 35 use only the tab '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: t f Name mrtm Address(if different from location) CityfTown State Zip Code Telephone Number B. Pumping Record 61 J 1. Date of Pumping g-(' 2" 2. Quantity Pumped: �� Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Wither(describe): r e �.✓�� 4. Effluent Tee Filter present? ❑ Yes Leo If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 6. SystW Pumped BTeA4�' Na Vehicle License Number S 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 3amc day Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts y City/Town of No. Andover 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 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: � / TO�z Q 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) oo ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): �/'' `5� e, 4. Effluent Tee Filter present? ❑ Yes J3,No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 6. System Pumped B : ame Vehicle License Number Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were disposed: 20 So. f4ill St., Br ford, MA ignature of Hauler Date C� Same Gay 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 W° 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 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 reb r f N I �0 Name ---- - ,sern Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Recordswo Y �� 1. Date of Pumping - 2. Quantity Pumped: 71 Date Gallons 3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap [Other(describe): U a e 4. Effluent Tee Filter present? ❑ Yes L? No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: goo 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 Commonwealth of Massachusetts �IM In City/Town of No. Andover 20�3 a System Pumping Record r` 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 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 enm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date G Z� - 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 compone t pumped: 6. System Pupped By: [)d 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 �LN Commonwealth of Massachusetts 1N� a1 W City/Town of No. Andover �P���,�EP 5tip23 System Pumping Record N SEP o 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 key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. 0-11 2. System Owner: Vs�=A Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping r� Z 3 2. Quantity Pumped: Uy Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank 91 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 JU['•(,/ 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