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
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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