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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