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HomeMy WebLinkAboutSludge Tank, Containment Room, Septic Tank, Grease Trap - Septic Pumping Slip - 351 WILLOW STREET 1/9/2023 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, 35'I l o use only the tab V" �J 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 N J fl _—__-- Name renm Address(if different from location) Cityrrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date Z 3 �Od 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap (21 Other(describe): 4. Effluent Tee Filter present? ❑ Yes<jg_No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed c ndition of component pumped: GQ0 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 'rt_-.. \IG^e- 5- Namgf Vehicle License Number Company 7. Location where contents were disposed: Stewart4 Rec ivin acilit , 20 So. Mill St., Bradford, MA 01835 PI f G J � See above �� JC� 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 I a System Pumping Record ;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 W 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: SameIVr o Name --- -- renm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Z Z 2. Quantity Pumped: Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): S/V 4. Effluent Tee Filter present? ❑ Yes E5-No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: &-4a� 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.-R-eceivin Facility, 20 So. Mill St., Bradford, MA 01835 L G � J u 'e 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 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 _ I / ) key to move your Address cursor-do not use the return City/Town State Zip Code key. 2. System Owner: reb / Name Address(if different from location) No.Andover MA City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Da e 7 2. Quantity Pumped. 51 1L? d ons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap dOther(describe): I V.'�9't 'f`AV_ 4. Effluent Tee Filter present? ❑ Yes VNo If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 6. System Pumped By: Z04, say) 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 /t' Q_S0,A T vn i s 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 �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: reb N' Same Name -- r�m Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record �2 �O C) I � 1. Date of Pumping Date ( � 2 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 ❑ No 5. Observed condition of component pumped: J d All of this estimated information is non-binding, valid o I 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 n 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 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 UVB uJ key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. 2. System Owner: teb Same Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Dat2 7-3 2. Quantity Pumped: G 1 00 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap [Other(describe): 61 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 tbA time of pumping. Not responsible beyond the date above. 6. Syste�lr Pu ped y: ot-w i Name Vehicle License Number Company 7. Location where contents were disposed: Stewart's RjeceivingFacility, 20 So. Mill St., Bradford, MA 01835 See above igna ure o 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 System Pumping Record Form 4 41y 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 ! 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: Samec�e �✓ 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: Galls 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: All of this estimated information is non-binding, valid only at the time of pumping. of 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 f y assachusetts City/Town of 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 ! �l/�11/0Ly key to move your Address cursor-do not MA use the return City/Town State Zip Code key. 2. System Owner: E a t� Name - eam Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record OG _ 1. Date of Pumping ldv Date 16V3 2. Quantity Pumped: Gall 3. Component: ❑ Cesspool(s) El Septic Tank ElTiat) Tank ❑ Grease Trap 9f-0ther(describe): 0 iq+gym r�1 OA— — 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 6. Syste mp d 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 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, �'� ���p 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 ! V D Name �n Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping ate Z 3 2. Quantity Pumped: Date Gallons 3. Component: ❑ Cesspool(s) t Y Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes (]K10 If yes, was it cleaned? ❑ Yes [j--'No 5. Observed condition,of compqnent pumped: �r •� All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. System umped 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 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, ll use only the tab key to move your Address cursor-do not use the return City/Town State Zip Code key. ❑1 2. System Owner: Name Address(if different from location) No.Andover MA City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping _h�e Date 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Fk Other(describe): �����<' - ✓�/,,,— 4. Effluent Tee Filter present? ❑ Yes 2-No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 6. System Pumped B 'Name Vehicle License Number Stewart's Septic 58 So Kimball St. , Bradford,MA Company 7. Location where contents were disposed: 20 So. WII St. Bradford,MA Signature of HauW 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 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, 0 w use only the tab �j VV key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. I1 2. System Owner:Same /v!,� V� _ &(14 f r Name — iafm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping r2� 23 2. Quantity Pumped'. Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): 4. Effluent Tee Filter present? ❑ Yes P9—No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: &06' 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 f Company 7. Location where contents were disposed: Stewaiys Receiving Facility,�8 So. Mill St., Bradford, MA 01835 r. /UI'1 ti ��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 City/Town of o P-nhv-e-i a 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 key to move your Address cursor-do not Mo Aw4 ve'K MA _ use the return City/Town State Zip Code key. 2. System Owner: reb I Same 'A) P J N Name ---- -- Address(if different from location) A)0 PW City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date Z� Z 3 2. Quantity Pumped: �a I' {on 6 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes d No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: joda, 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: ACgaV'1 Name Vehicle License Number Company 7. Location where contents were disposed: SSt^ew,.art's Receiving Facility, 20 So. Mill St., Bradford, MA 01835 g a yl To Yve 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, 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: / Same Name - ------ -- �un Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date - Z3 2 Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): j et 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 6—oe'a 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 u/aF rS -S Company 7. Location where contents were disposed: Stewart' Receivinq Facility, 20 So. Mill St., Bradford, MA 01835 G 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 Sr`,9 i ,b0a59:;- yo, e - tl .n" --�.^�'�"' -�+-a+:.s •,,,. ,ate_ r o= . =a Tu �; •a t try,-. - � _ " took IL Commonwealth f M s achusetts City/Town of o vi�_r 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 /1)J' key to move your Address cursor-do not MA use the return key. City/Town State Zip Code 2. System Owner: t� Same 7`nn t) Name ICI v Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 5 1. Date of Pumping 2. Quantity Pumped: --do - 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 T dition of component pumped: g"�V UAll of this estimated information is non-b n , valid only at the time of pumping. Not responsible beyond the date above. 6. System P ed,By: 1 r)k Cc Name Vehicle License Number Company 7. Location where contents were disposed: Stewart's Receiving FFacility,_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