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HomeMy WebLinkAboutSeptic Tank, Sludge Tank - Septic Pumping Slip - 351 WILLOW STREET 3/5/2024 <L�- Commonwealth of Massachusetts City/Town of No. Andover h - 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, l/vw `t use only the tab 1 t key to move your Address r� cursor-do not No. Andover ! r MA 01845 _ use the return City/Town State Zip Code key. 2. System Owner: rab p Same Name Address(if different from locatiop)e�' i City/Town N� State Zip Code Telephone Number B. Pumping Record e G 1. Date of Pumping Date Z ~2 Z y 2. Quantity Pumped. Gallons 3. Component: ❑ Cesspool(s) ©'Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes K�'No If yes, was it cleaned? ❑ Yes 2'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: l�1 Y L 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 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, 5 /l J/� use only the tab b � I 111) key to move your Address tA (� cursor-do not No. Andover © � use the return $in MA 01845 key. City/Town State Zip Code 2. System Owner: �QR 5 1014 tab Same r Name Address(if different f tion) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping z 12 — 2 2. Quantity Pumped: Date Gallons 3. Component: ❑ Cesspool(!s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): �� - 4. Effluent Tee Filter present? ❑ Yes E3-No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed con n of component pumped: _L7 C90 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 ' T Company 7. Location where contents were disposed: Stewart' Receivinq Facility, 20 So. Mill St., Bradford, MA 01835 fps -- Cl- �J(1��5 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 �m 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: I on the computer, use only the tab key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town key. TOW n o� AlINI IUV State Zip Code 2. System Owner: r� Same _ o n 2024 �*�� LA IrLJ Name reern Address(if different from location th Hea �e�a CityFrown 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 [a"-Other(describe): � �^ ✓ --- 4. Effluent Tee Filter present? ❑ Yes M\No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed dition of component pumped: :7 �9r 6V All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. System Pumped_ 0�—' "j � C� Name Vehicle License Number -- C'J C � Company 7. Location where contents were disposed: Stewart's Receivin Faci , 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 _ 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, Ver use only the tab o �gd key to move your Address �� v AU" cursor-do not No. Andover 10 MA 01845 use key the return Cityrrown ROC 2. System Owner: 2024 State Zip Code N1Q J f� nt s WI Gw S 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 ('�vp > 3. Componerpt:- ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): 4. Effluent Tee Filter present? ❑ Yes B—No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed co ition of component pumped: r e 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 Name Vehicle License Number 6410 Crr Company 7. Location where contents were disposed: Stewa 's Receivin 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 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, I / use only the tab key to move your Address OW cursor-do not No. Andover MA 01845 use key the return City/Town O 2024 State Zip Code 2. System Owner: MAR Same Name Bea ream Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date C 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ❑ Septic�Tank,� El Tight Tank El Grease Trap ❑ Other(describe): S 1 U�g e q1'a- 4. Effluent Tee Filter present? ❑ Yes []/No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: Q 1 d © L 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.S a Name Vehicle License Number Company 7. Location where contents were disposed: Stewart's Receiving Facility, 20 So. Mill St., Bradford, MA 01835 //LjaS0y1 J J#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 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, 251 wrI�UVtr �� use only the tab r .1r..lr�� key to move your Address '` �— IUV � cursor-do not No. Andove�o%o 1' MA 01845 use the return City/Town State Zip Code key. 2. System Owner: MAR Q 5 2024 t� f I Same Name ream 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 Q Other(describe): 5Uq(4P__ ` iJ � 4. Effluent Tee Filter present? ❑ Yes R No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: / r 'e% 'P d U( 00 All of this estimated information is non-binding, valid only allMe tirrfe of pumping. Not responsible beyond the date above. 6. System P sped By: — :Yl / l�ce-- Name .0 J Vehicle License Number Company 7. Location where contents were disposed: Stewart's Receiving Fqgjlity, 20 So. Mill St., Bradford, MA 01835 See above of er Date Signature of Receiving Facility(or attach facility receipt) Date \ t5form4.doc•11/12 System Pumping Record•Page 1 of 1 1 Commonwealth of Massachusetts W 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, 3rl I�w Sy use only the tab 7 GU l key to move your Address t 0 � cursor-do not No. Andover)%n ©1 MA 01845 use the return City/Town State Zip Code key. 2. System Owner: MAR 0 5 2024 � ,N , T Same � o Name -- t- ^Pa rearm - Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record E2110.F 1. Date of Pumping Date` l� ZY 2. Quantity Pumped: Gallons 5r� 3. Component: ❑ Cesspool(s) /❑ Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): / U`�����✓�� 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of ompongnt pumped: Ltw All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. System Rumped V, Z'qmi�� Name _ 5-D Vehicle License Number Comp ny 7. Location where contents were disposed: Stewart's Receiving Facilit , 2y 0 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 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, -351 w►I l" S use only the tab I key to move your Address cursor-do not No. Andover MA 01845 use the return key. City/Town 2024 State Zip Code 2. System Owner: MAR 0 5 f� t f Ja Same Name sus " Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping z T 2. Quantity Pumped: 3�odd Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap [Other(describe): S I U d 9e �=� 'Y' - 4. Effluent Tee Filter present? ❑ Yes [v/No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: J OO'� 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: �� CQ`q Name Vehicle License Number Company 7. Location where contents were disposed: Stewart's Receiving Facility, 20 So. Mill St., Bradford, MA 01835 114�0 -COY1 f rol �'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 No. Andover System Pumping Record Form 4 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. Ando1 ;1�� l� MA 01845 use the return key. City/Town State Zip Code r� 2. System Owner: MQR Q 5 2024 r n ' Same r Name Address(if diff4ehYfFom location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. QuantityPumped: p g Date p Gallons 3. Component: ❑ Cesspool(s) s❑ Septic Tank El Tight Tank ❑ Grease Trap [� Other(describe): " c/J �Nll 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: z'iye)2 All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. Sys m Pum ed By: 0/1-- Na Vehicle License Number C mpany 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 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, �v��4UW use only the tab �.��s�� ...) key to move your Address t �`1�� cursor-do not No. Andoy! in 0i`�Ui�1 MA 01845 use the return 4� ' City/Town key. `a State Zip Code �p24 2. System Owner: MAR 0 5 Same ',1�' JoU Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record Z-73 - 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 Z�No If yes, was it cleaned? ❑ Yes jz*lo 5. Observed condition of componen mped: All of this estimated information is non-bieding, valid 6nly at the time of pumping. Not responsible beyond the date above. 6. System Vplt- Name Vehicle License Number Company 7. Location where contents were disposed: s Receiving a 0 So. Mill 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 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: A ' on the computer, `e ,i ,`� P,n ®fir use only the tab key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town �Q O 5 State Zip Code key. R 2. System Owner: / f� Same Name anrn Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record �I 1. Date of Pumping L 2. Quantity Pumped: l 000— ---- Date Gallons 3. 70therponent: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap (describe): ( U c 9 4. Effluent Tee Filter present? ❑ Yes E� No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 3 0 Q 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: /`'agog Name Vehicle License Number Company 7. Location where contents were disposed: Stewart's Receiving Facility, 20 So. Mill St., Bradford, MA 01835 D' SO n -&70--C-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