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HomeMy WebLinkAboutSludge Tank, Septic Tank - Septic Pumping Slip - 351 WILLOW STREET 1/9/2024 �LN Commonwealth of Massachusetts o�P� lugCity/Town of No. AndoverSystem Pumping RecordForm 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, 35 use only the tab key to move your Address cursor-do not No. Andover MA 01845 use the return Cityrrown state Zip Code key. 2. System Owner: r Same Name rdum Address(if different from location) CityrTown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping f 2�— 2. Quantity Pumped: Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): ��V�� Ir 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 672C'2 0 All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. System mped By: Nam 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 Nb ovgk Vqo ° 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 �yi (p Li key to move your Address cursor-do not MA use the return City/Town State Zip Code key. 2. System Owner: Same &L, J e ` Name law Address(if different from location) Cityrrown State Zip Code Telephone Number B. Pumping Record _ c � Z3 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) t['Septic Tank [] Tight Tank ❑ Grease Trap ❑ Other(describe): MI 4. Effluent Tee Filter present? ❑ Yes L� No If yes, was it cleaned? ❑ Yes C No 5. Observed condition of c mponen pumped: All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. System Pu d By: ` 0Wv�<< 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. A7'koej 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, ?�!� wf�l oW �L use only the tab 7 key to move your Address cursor-do not No. Lf.Af.p yz4, MA use the return key. Cityrrown State Zip Code r� 2. System Owner: Same a ke N �� Name — ----- — —— -- ,ehn, Address(if different from location) City/Town State Zip Code -- Telephone Number B. Pumping Record 1. Date of Pumping �3 2. Quantity Pumped: Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): �`� 4. Effluent Tee Filter present? ❑ Yes �o If yes, was it cleaned? ❑ Yes ❑ No 5. Obs=dd't' n 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. S s m Pump 0 , e _ N e Vehicle License Number �wG 'S Com any 7. Location where contents were disposed: Stewa ' Receivin Facility, So. Mill St., Bradford, MA 01835 See above 1,�2 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1 i 1 ,� a If Commonwealth of Massachusetts u City/Town of No. Andover } System Pumping Record so To 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, 57 /v n Sr use only the tab l V -C.�Dz..� key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. 2. System Owner: /l r� Same Name - — rertm 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 1 ' her(describe): S/�� - 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: l/ U 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: Nam 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 9 tioti� System Pumping Record LPN ` 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 c L/ key to move your Address cursor-do not W,, ��/► MA use the return CityfTown State Zip Code key. 2. System Owner: Same k ' Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 12, 'ZI 2. Quantity Pumped: Date Gallons 3. Component: ❑ Cesspool(s ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): v 4. Effluent Tee Filter present? ❑ YesNo If yes, was it cleaned? ElY4 5. ee cj�ndition,o component l�mp nt pped: 7 (�/ L All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. S I m Pumped By- Name Vehicle Li I se Number Company 7. Location where contents were disposed: tewart's Receiving Facilit , 20 So. St., Bradford, MA 01835 See above Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1