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HomeMy WebLinkAboutSlude Tank, Grease Trap - Septic Pumping Slip - 351 WILLOW STREET 2/6/2024 LN Commonwealth of Massachusetts � o�hAndo`��e W City/Town of No. Andover �`' '\ System Pumping Record VIE Form 4 �k M ,ve DEP has provided this form for use by local Boards of Health. Other forte 1�1t��1,'but the information must be substantially the same as that provided here. Before�u� ga 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, �ZZ51 �l<I W 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: t� V t. 'IV J�� Same Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date y 2. Quantity Pumped: Gals 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap ,�- J_ Other(describe): ` �—J(J55y ���~ 4. Effluent Tee Filter present? ❑ Yes to If yes, was it cleaned? ❑ Yes ❑ No 5. Oreq ved 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_ v Name Vehicle License Number Company 7. Location where contents were disposed: Ste Receiving Facility, 20 So. Mill St., Bradford_, MA 01835 P C A J See above a _a Signature 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 T°v�� °# N©rth And°ver City/Town of No. Andover System Pumping Record FEB p s 2024 Form 4 y M �{ DEP has provided this form for use by local Boards of Health. Other 11oj-ms 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, �S� Vv l f I D w 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: � r , t� / Q I Same I�- /lJv Name ienm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record r- 2 1. Date of Pumping q-Date 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap E ther(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: c All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. Sys m Pumped y: Na a Vehicle License Number Company 7. Location where contents were disposed: Stewart's Receiving Facili�, 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 Tc �m ' cAndover N City/Town of No. Andover FEB 0 6 2024 w° System Pumping Record Form 4 �M Waith Denartment 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 ✓� 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 r— Same - lti? J o Name team Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record ZY 1. Date of Pumping Date _ 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap [�f~Other(describe): Sl u�+G, e G/✓�� 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: �J 0 C' All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. SysteR Pumped B 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 Town of t%1-rth Andover w City/Town of No. Andover System Pumping Record FEB 0 6 2024 Form 4 M .,.��� DEP has provided this form for use by local Boards of Health. Other farlai�grnay#be 1us6d;`6u t eent 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 b(nj 7 — key to move your Address cursor-do not No. Andover MA 01845 use the return key. City/Town State Zip Code 2. System Owner: /V �- � Same , �ol Name ,gym Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record cq3 0 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): "310 !` - 4. Effluent Tee Filter present? ❑ Yes,2 No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 5)ud'- All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. System P ped 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 atur of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 Towr Andover IL Commonwealth of Massachusetts W City/Town of No. Andover FEB 0 6 2024 4° System Pumping Record Form 4 Health D partment �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 3-5-f key to move your Address cursor-do not No. Andover MA 01845 use the return key. City/Town State Zip Code 2. System Owner: red Same /-- - IJ��_ �i�i Joy Name 2mnn Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date _(2 Z 2. Quantity Pumped: Gallonsf ` 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap E2`10—ther(describe): S/y, �e 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: &:y-0d All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. System Pumped Bemu— Narne(// : 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 Tcdv a� � th Andover ILN Commonwealth of Massachusetts W City/Town of No. Andover FEB 0 6 2024 System Pumping Record Form 4 Health Depaltment GM 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, f� use only the tab 35-/ key to move your Address cursor-do not No. Andover MA 01845 use the return — key. City/Town State Zip Code 2. System Owner: r� Same Name ream Address(if different from location) Cityrrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2 Z 2. Quantity Pumped: 3,OO J -- Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank El Tight Tank El Grease Trap ❑ Other(describe): 5/h d -�t-a �G 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: V co y C U All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. Sys P ped By' 7i/ Na a Vehicle License Number Company 7. Location where contents were disposed: Stewart's Receiving Facility, 20 So. Will 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 I �LN Commonwealth of Massachusetts lu�ti' C svitS� Andover ' u W City/Town of No. Andover o System Pumping Record FEB 0 6 20A Form 4 (( aye' 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 key. City/Town State Zip Code 2. System Owner: 6„ t Same (&t V D Name --- - Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping —��' �z 2. Quantity Pumped: 3 oo o Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap � Other(describe): �w�`�G _ 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 50o � All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. Syst m Pumped By: 7aso-0 Name Vehicle License Number Company 7. Location where contents were disposed: Stewart's Receiving Facility, 20 So. Mill St., Bradford, MA 01835 ! _(a SQL joy " 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 �1'#�`3a .!,iOc.. # .aJ �.t'r7 �-'i°'+� �$J: �' �'A:.i.:� �✓� r li � t , S I i 'Ao "�"'twe;�wn. a:,� " -a. t_•Yanr'+r. ,, ._.. ..+� -:ts]. Commonwealth of Massachusetts TO arP of Nofth Andover W City/Town of No. Andover o System Pumping Record FEB 0 6 2024 Form 4 ryy 'i^0 Lt DEP has provided this form for use by local Boards of Health. Ottjer forms maybe 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: r� Same Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Z- 2. Quantity Pumped: 3, 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 condition of component pumped: U 7pod-- All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. Sys V mped BWt �-- Na 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 Andover City/Town of No. Andover _ System Pumping Record FEB 0 6 2024 Form 4 G7H r..F 1,-1 C'01-L-11lent DEP has provided this form for use by local Boards of Health. Of fotMs 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� r Same t �I Name sam Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 0 - 1. Date of Pumping (- �Z 2. Quantity Pumped: A 5 /� Date Gal ons 3. Component: ❑ Cesspoo(l(�s,)� El Septic Tank [I Tight Tank El Grease Trap Other(describe): s)crJ' ��� - 4. Effluent Tee Filter present? ❑ Yes 2/No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: . `� lJ All of this estimated information is non-binding, valid only at the timeef pumping. Not responsible beyond the date above. 6. Syste umped By- - I �� K r,&�,_ Name Vehicle License Number Company 7. Location where contents were disposed: Stewart's Rgreiving Facility, 20 So. Mill St., Bradford, MA 01835 See above gnature 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 TO City/Town =W R' Andover City/Town of No. Andover System Pumping Record FEB 0 6 2024 Form 4 JAM 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, 2�� VVi do � �L— use only the tab 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: VkA Same <� N ' o Name --- - Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping - ' w 2. Quantity Pumped: 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 condition of component pumped:) ',, *�-a iv'' &r�'`'� All of this estimated information is non-binding, valid only at the time of-pumping. Not responsible beyond the date above. 6. System Pum a 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 Town of Noah Andover a System Pumping Record Form 4 FEB 0 6 2024 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, ohesk vAth 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 � � V" 1 Vp W key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. �1 2. System Owner: Same f r aU.Q To Name ienm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping �— 23 2. Quantity Pumped: Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap [Other(describe): bL 4. Effluent Tee Filter present? ❑ Yes [�JXNo If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component_pumped: O All of this estimated information is non-binding, valid only at a time of pumping. Not responsible beyond the date above. 6. SystemPumped B Name Vehicle License Number Company 7. Location where contents were disposed: Stewart's Receiving Facility, 20 So. Mill St., Bradford, MA 01835 See above Signatu auler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1 �LN Commonwealth of Massachusetts T`'.' Andover City/Town of No. Andover System Pumping Record FEB 0 6 2024 Form 4 M DEP has provided this form for use by local Boards of Health. Other forms may Jae 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 v t�I 0 w 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: Same Name ---- nem Address(if different from location) City/Town State Zip Code Telephonq Number B. Pumping Record 1. Date of Pumping �O Z 2. Quantity Pumped: b�00 d Date Gallons 3. Component: ❑ Cesspool(s) ❑ Sceptic Tank ❑ Tight Tank El Grease Trap [Other(describe): I u Age— �a n� 4. Effluent Tee Filter present? ❑ Yes Er N0 If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 3 OC)& 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 OL's 6-YA �'Q re Q 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 Andover City/Town of No. Andover a ° System Pumping Record FEB o 6 20 24 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 1l 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 S I!v► U 0 L'U YI Name Address(if different from location) CityfTown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: cal lons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank lop Other(describe): --- 4. Effluent Tee Filter present? ❑ Yes ®--No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: C.y "'' � All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. System Pumped � c3zl) Vehicle License Number ale, fS Company 7. Location where contents were disposed: Stewart', ecQ,tvingFacility, 20 S fl St., Bradford, MA 01835 See above i�auler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 TQW/7 Commonwealth of Massachusetts W City/Town of No. Andover FEB 0 s 20 a System Pumping Record 24 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� de L U 1 5' — 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: r� Same �I Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record to 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ❑�}S-eptic Tank ❑ Tight Tank ❑ Grease Trap [Other(describe): 4. Effluent Tee Filter present? ❑ Yes Z/No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: L)d All of this estimated information is non-binding, valid at the time of pumping. Not responsible beyond the date above. 6. S !Leem Pumped By: Name ^ Vehicle License Number Company 7. Location where contents were disposed: Stewart's Receivin Facilit 20 So. Mill St., Bradford, MA 01835 See above ignature of Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1