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HomeMy WebLinkAboutSeptic Tank, Sludge Tank, & Grease Trap - Septic Pumping Slip - 351 WILLOW STREET 10/27/2023 Commonwealth of Massachusetts W City/Town of No. Andover System Pumping Record Form 4 L 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: ✓— Same (_ Name ream Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 7 01� 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 M/No If yes, was it cleaned? ❑ Yes [�No 5. Observed condition of comp ent pumped: All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. System Pumped By: Name Vehicle License Number Company 7. Location where contents were disposed: Stewart's Receivinq Facility 20 So.- Mill St., Bradford, MA 01835 See above Signature of Hauler Date 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 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 VU IN 7 key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. 2. System Owner: y, Same Jft Name -- - ream 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): c5) `f ,f-r, t 1-7 - 4. Effluent Tee Filter present? ❑ Yes CF2"o If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: C�) All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. System Pumped ,. Name Vehicle License Number Company 7. Location where contents were disposed: StewartyReceiving Facility, 20 So. Mill St., Bradford, MA 01835 See above Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts w W City/Town of No. Andover 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, ��✓` �� S 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: rab Same (U f �Q Name ----- Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping pate 6 ' 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): 4. Effluent Tee Filter present? ❑ Yes 0.-No If yes, was it cleaned? ❑ Yes ❑ No 5. Ob/s�erved ondition of component pumped: lid All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. System Pumped By: N Vehicle License Number oc1-%S 'Sc ,/i Zs Company 7. Location where contents were disposed: Stew 's Receivinq Fa�cilitl 0 So. Mill St., Bradford, MA 01835 / See above A) Signature of Hauler Date 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 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, 351 W I ti use only the tab _— 1 key to move your Address cursor-do not No. Andover _ _ MA 01845 use the return City/Town State Zip Code key. 2. System Owner:VILA i Same L�Jo Name nrtm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping ---j 2. Quantity Pumped: �CG Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): __5L, 4 4. Effluent Tee Filter present? ❑ Yes 0�_No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: r�Q C)to All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. System Pumped : \\j Name Vehicle License Number Company 7. Location where contents were disposed: Stewart's Regeiving,Facility, 20 So. Mill St., Bradford, MA 01835 JI-11i /C) �C=T See above b;tigna re of Hauler Date 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 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 Vim► U(it� S 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� r Same G� !V Jp, 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 KGrease Trap ❑ Other(describe): — 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: All of this estimated information is non-binding, valid only at the time of pumpingf. Not responsible beyond the date above. 6. System Pumped By: I�I Name Vehicle License Number Company 7. Location where contents were disposed: Stewart's Receiving Facility, 20 So. Mill St., Bradford, MA 01835 _ See above Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 r - ., CLUL vc Commonwealth of Massachusetts - City/Town of No. Andover 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, �a f,„ A �Q use only the tab �1� 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� Same Name --------- ienm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1 (6 - (3-? 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 component pumped: �;'voLA All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. SysteR Pumped By: ,�,v�--- Name Vehicle License Number Company 7. Location where contents were disposed: Stewart's Receivinq Facility, 20 So_ Mill St., Bradford, MA 01835 See above Signature of Hauler Date 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 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, /i a� (� use only the tab %%�� V V 1(, ..! 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� Same . r/V / 'T f — Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping [0 r (? Z - 2. Quantity Pumped: 50 n - Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap T(Other(describe): I U oL 9 n e r- - — 4. Effluent Tee Filter present? ❑ Yes 17(No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 100& All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. System Pumped By: Name Vehicle License Number &CtNct t- ll-,S Se P} L _ — Company 7. Location where contents were disposed: Ste�wwart's ReceivingFacility, 20 So. Mill St., Bradford, MA 01835 /" t a ,o n sov S See above Signature of Hauler Date 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 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, �Gj( I A i(((0 ij S ' use only the tab V key to move your Address cursor-do not No. Andover _ MA 01845 use the return City/Town tate Zip Code Y r� 2. System Owner: Same IUU ka0(r-e 1 Name -- - Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping t� r� '2 2. Quantity Pumped: Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap 0 Other(describe): S L o d g e- 4. Effluent Tee Filter present? ❑ Yes [� No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 3 00-� All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. System Pumped By: /' OL - Name Vehicle License Number Company 7. Location where contents were disposed: Stewart's Receiving_Facility, 20 So. Mill-St., Bradford, MA 01835 `(J 90yj -)P(1Ae-$ See above Signature of Hauler Date 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 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, S�t �n/ ,r n ` use only the tab _ V v�-0'vJ key to move your Address cursor-do not No. Andover use the return MA 01845 key. City/Town State Zip Code 2. System Owner: Same f /" Name rerun Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping (v zo 23 2. Quantity Pumped: Date Gallons 3. Compo nt: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): -fie 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. O served, ondition of component pumped: ���� All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. Sys m Pumped Name Vehicle License Number Company 7. Location where contents were disposed: Stew fs Receiving Facility, 20So. Mill St., Bradford, MA 01835 See above Signature of Hauler Date 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 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 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: J Same Cc /" Jo _ Name - —- ---- rdvn Address(if different from location) CVITown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped. Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ElTight Tank ElGrease Trap S Other(describe): /V &e, /---- - 4. Effluent Tee Filter present? ❑ Yes Flo If yes, was it cleaned? ❑ Yes ❑ No 5. Observed co dition of component pumped: �;-" All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. System Pumped B Name Vehicle License Number Company 7. Location where contents were disposed: SteWaA Receiving Facility, s2 o. Mill St., Bradford, MA 01835 1 \� + See above Signature of Hauler Date 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 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 VV ( J key to move your Address cursor-do not No. Andover MA 01845 use the return — key. City/Town State Zip Code r� 2. System Owner: r i Same - Cc Name - Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping - - 2. Quantity Pumped: T ^ d Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): - `5�10ci�'e /7Z�vie 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. Syste Pumped By:n Name Vehicle License Number Company 7. Location where contents were disposed: Stewart's ReceivingFacility, 20 So. Mill St., Bradford, MA 01835 See above Signature of Hauler Date 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 o ov�iV/ T # 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, 2�r I A II/lo� use only the tab 11 1 VV 1 key to move your Address cursor-do not MA use the return City/Town State Zip Code key. 2. System Owner: r� Same �� '/V J� Name rerun Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record to - 2 7=T- - �; O Q a 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): - S 1 U d3 L +0'6yC.-- -- -- 4. Effluent Tee Filter present? ❑ Yes [f No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 3 00'� All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. System Pumped By: IA10--s ory1 — Name Vehicle License Number Company 7. Location where contents were disposed: Stewart's Receivin Facility, 20 So. Mill St., Bradford, MA O-Sxn -or. is See above Signature of Hauler Date N/A 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 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 w J 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: / Same Name -- - r�m Address(if different from location) Cityrrown State Zip Code Telephone Number B. Pumping Record t1- 3r - 1. Date of Pumping Date Z 3- 2. Quantity Pumped: C5 Gall�?e do ons 3. Compone ❑ Cesspool(s) ❑ Septic Tank El Tight Tank ❑ Grease Trap Other(describe): 4. Effluent Tee Filter present? ❑ Yes [A_No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed co ition of component pumped: All of this estimated inPorm:fa&tioLnis non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. System Pumpe d , /Na'm-e _ Vehicle License Number Company 7. Location where contents were disposed: Stewa;t's,Receiyjng Fa it , 20 So. Mill St., Bradford, MA 01835 C See above Al Signat a of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1