HomeMy WebLinkAboutSludge Tank, Tight Tank, Septic Tank - Septic Pumping Slip - 351 WILLOW STREET 12/11/2023 Commonwealth of Massachusetts
W City/Town of No. Andover
System Pumping Record pE� t 12023
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, z I V p
use only the tab /5-/ V f�t Q k✓
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:
Same
Name
rerun
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ms Dat—e Z 2. Quantity Pumped: Gauoyly
3. Component: ❑ Cesspool(s) ElSeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ C
Other(describe): )yd y { j;/VX
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed con ion of component pumped:
7�0 CA All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. Syste Pu ped By:
Na y
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
Commonwealth of Massachusetts
W City/Town of No. Andover ,� 12p23
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, ��1
use only the tab "" /Id�� FYI
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key. p
2. System Owner:
rab
( "�� Same /V
�I Name ----
renen
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 0- 3 - Z3Date --- 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ET'No If yes, was it cleaned? ❑ Yes SIN
5. Observed condition of componen 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:
�' a t' ott"
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
Commonwealth of Massachusetts
F w City/Town of No. Andover
a
System Pumping Record oEC ,112�23
G7M Sy6
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.
t� 2. System Owner: `
Same _ aVV
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date( Z� 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank [Tight Tank ❑ Grease Trap
❑ Other(describe): � —
4. Effluent Tee Filter present? ❑ Yes LT/No If yes, was it cleaned? ❑ Yes_[]No
5. Observed condition of componen 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 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
Commonwealth of Massachusetts
H City/Town of No. Andover oE� 12023
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 r t
key to move your Address
cursor-do not No. Andover MA 01845
use the return
key. City/Town State Zip Code
2. System Owner.-
Same
Name
renvn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping patl'J b Z3 2. Quantity Pumped: 'c � —
Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
ther(describe): �� s�- -_��.-7 A
4. Effluent Tee Filter present? ❑ Yes E&No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
0 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 By:
Name Vehicle License Number
-51�t v✓ai Js
Company
7. Location where contents were disposed:
Stewaq,'§ Re ceivinQ,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
H City/Town of No. Andover
System Pumping Record oEC 11
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 1 / ��
use only the tab > > 1 �V t , ��(OGt�
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town
key. State Zip Code
2. System Owner:
r� Same
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: canons
3. Component: ❑ Cesspool(s) (Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): — -- —
4. Effluent Tee Filter present? ❑ Yes B No If yes, was it cleaned? ❑ Yes E�10
5. Observed condition of compone 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 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
_ Commonwealth of Massachusetts
W City/Town of No. Andover 2023
a 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 77 3/1
key to move your Address
cursor-do not No. Andover _ MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
tab
Same
Name - _-- — —
renen
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping —Z5--- 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe): - --
4. Effluent Tee Filter present? ❑ Yes 2-No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
Bd J- 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 Receiving Facility, 20 So. Mill St., Bradford, MA 01835
See above 1 I'l y Q3
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc- 11/12 System Pumping Record-Page 1 of 1
'C\ Commonwealth of Massachusetts
W City/Town of No. Andover SEC 12023
System Pumping Record
Form 4
G 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 V0 f(,a,, fl�
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.
t�
2. System Owner:
Same
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 L-No If yes, was it cleaned? ❑ Yes [T No
5. Observed condi 'on of corlponent 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:
r 0 "V
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.doca 11/12 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
= City/Town of No. Andover
W° System Pumping Record �C
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, u��l�o S�
use only the tab _ _. r"
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
Same_
Name
return
Address(if different from location)
City/Town State Zip Code
--- _ Telephone Number
B. Pumping Record
1. Date of Pumping oat, Z3 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ElTight Tank ElGrease Trap
Other(describe): C-3 C/
4. Effluent Tee Filter present? ❑ Yes �ANo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
(0 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✓_
Nye Vehicle License Number
Company
7. Location where contents were disposed:
Stewa Receivin acilit , 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 Zp23
Y p 9 EC 11
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 computers'
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�
Same
Name J v
rerun ,.
Address(if different from location)
City/Town State Zip Code
_ Telephone Number
B. Pumping Record
1. Date of Pumping Date fl-2( - 23 2. Quantity Pumped: (J G� CJ
Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe):
A—_
4. Effluent Tee Filter present? ❑ Yes [&No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
lT Oy j 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:
vName Vehicle License Number
Company
7. Location where contents were disposed:
Stewa s Receiving Facility, 20 o. 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
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, 5I WI r/d Sf use only the tab
key to move your Address
cursor-do not No. Andover MA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
Same
Name ----- —
renm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date Zy Z3 2. Quantity Pumped: Gallons
3. ;;7pon: ❑ Cesspool(s) El Septic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑ Yes (Mo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed 7cndition
of component pumped:
l `� �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
vName Vehicle License Number
�,��r s
ompany
7. Location where contents were disposed:
Stewart's J(eceivipq Facility, 20 ill St., Bradford, MA 01835
See above
ignature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
If
Commonwealth of Massachusetts
�N 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:
t� JiL 'N
_Same �y
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) n/septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Z No If yes, was it cleaned? ❑ Yes Flo
5. Observed condition of cn nt 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:
fPm-t
Nam6 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