The URL can be used to link to this page

Home My WebLink AboutSludge Tank, Tight Tank, and Septic Tank - Septic Pumping Slip - 351 WILLOW STREET 4/2/2024 Commonwealth of Massachusetts W City/Town of No. Andover System Pumping Record iG M Form 4 APR 9 2 M24 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 �Vdo of S� 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 ream Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: Ll Cl�l 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: 6 0 L-. All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. Sy em Pumped y: Na nr6e-1 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 t5forrn4.doc•11/12 System Pumping Record•Page 1 of 1 �L\ Commonwealth of Massachusetts W City/Town of No. Andover System Pumping Record APR 0 2 2024 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 �5 / S V t/l bL 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 (,��. Job Name yearn Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Z 2 2. Quantity Pumped: Date Gallons 3. 70th ponent: ElCesspool(s) ❑ Septic Tank ElTight Tank ElGrease Trap er(describe): _ ge 4. Effluent Tee Filter present? ❑ Yes E No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 1 6.Q 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: '/-�O( 5 Name Vehicle License Number Company 7. Location where contents were disposed: Stewart's Receiving Facility, 20 So. Mill St., Bradford, MA 01835 /AOt-,36 Y^ S64-tPj See above Signature of Hauler Date 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 APR 0 2 2024 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, �t/t� oo use only the tab > / �/V key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. 2. System Owner: V� Same Jal� o Name - ------- renen Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 2 1. Date of Pumping 2. Quantity Pumped: Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap [Other(describe): - --- U d 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: J ca'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: / AaSG YI _ Name Vehicle License Number Company 7. Location where contents were disposed: Stewart's Receiving Facility, 20 So. Mill St., Bradford, MA 01835 t4,0L S a r fbf'-t 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 n City/Town of No. Andover Pumping System S Record APR 12 202A Y p� 9 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. 2. System Owner: Same Name —-- -- r�m 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. 70therponent: ❑ Cesspool(s) ElSeptic Tank ❑ Tight Tank ❑ Grease Trap (describe): S 1 U d 9-0_ 4. Effluent Tee Filter present? ❑ Yes M No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: goo 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: �,Cr _ Name Vehicle License Number Company 7. Location where contents were disposed: Stewart's Receiving Facility, 20 So Mill St., Bradford, MA 01835 , `agcyl -fc)A 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 APR 0 2 2024 ' 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, r use only the tab W�#0W J 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 1 f 69 Name - — ream Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 7 ZZ 2. Quantity Pumped: Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): - ` lo4 ��`�L 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition oofff component pumped: U-yo G All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. Syst Pumpe y: N m 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 - u W City/Town of No. Andover W° System Pumping Record APR 0 2 2024 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, �St oil lW0W use only the tab _ �/ key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town S to Zip Code key. r� 2. System Owner: Same Name -- - Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping C� Z 2. Quantity Pumped: ��C)O Datee � Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap []/Other(describe): 4. Effluent Tee Filter present? ❑ Yes [:I/No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: S)UJ'A'e— All of this estimated information is non-binding, valid only t the time of pumping. Not responsible beyond the date above. 6. System Pumped By: zq(K &6(- Name Vehicle License Number So f any 7. Location where contents were disposed: Stewart's Receiving Facility, 20 So. Mill St., Bradford, MA 01835 See above n er Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts u 'v` City/Town of No. Andover -_ System Pumping Record APR 0 2 2024 iG^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 key to move your Address cursor-do not No. Andover MA 01845 use the return Cityrrown State Zip Code key. 2. System Owner: I Same N Name / Address(if different from location) City/Town State Zip Code Telephone Number . B. Pumping Record 1. Date of Pumping � � - 2. Quantity Pumped. 50o - Date to Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): - i ----�� 4. Effluent Tee Filter present? ❑ Yes []-No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 3) Ud All of this estimated information is non-binding, valid only at t time of pumping. Not responsible beyond the date above. 6. System Pumped By: 7zy� Name Vehicle License Number om 7. Location where contents were disposed: Stewart's Receiving Facility, 20 So. Mill St., Bradford, MA 01835 See above S' uler 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 NMh Andover W City/Town of No. Andover System Pumping Record APR 0 2 2024 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, (MA)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. �1 2. System Owner: V� Same (te- I ' jcq 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 3. Component: ❑ Cesspool(s) ❑ Septic Tank Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes KRINo If yes, was it cleaned? ❑ Yes E No 5. Observed condition of comp ent 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: 3 ✓yl''Lip"c. 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 :gin cI I rin Andover Commonwealth of Massachusetts W City/Town of No. Andover APR 0 2 2024 a 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, A-/ use only the tab ( J key to move your Address cursor-do not No. Andover MA 01845 use the return CityTTown State Zip Code key. 2. System Owner: r� ` Jo Same Name rim Address(if different from location) CityTTown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 12 Dat r Z 2. Quantity Pumped: 3. Co ponent: ❑ Cesspool(s) Septic Tank ❑ Tight Tank El Grease Trap �- - Other(describe): Uo- — 4. Effluent Tee Filter present? ❑ Yes [�/Nlo If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped. 100 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 Company 7. Location where contents were disposed: Stewart's Receiving Facility, 20 So. Mill St., Bradford, MA 01835 (x �\ 0S See above Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date System Pumping Record•Page 1 of 1 t5form4.doc•11/12 Commonwealth of Massachusetts Town of Wth Andover a W City/Town of No. Andover System Pumping Record APR 0 2 2024 Form 4 M Ly 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. 2. System Owner: r _ ref Same �I Name ------- rerun Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping g r2 2. Quantity Pumped: Date Gallons 3. 70th onent: ❑ Cesspool(s) ElSeptic Tank ElTight Tank ❑ Grease Trap er(describe): �Gn/!� 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 6,-7)ad All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. Syst Pumpe��. � M� Nam Vehicle License Number Company 7. Location where contents were disposed: Stewart's Receivi_�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 NoO Andover u W City/Town of No. Andover System Pumping Record APR 0 2 2024 Form 4 GSM R., ment 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 A ,,I use only the tab V�/ 61I key to move your Address cursor-do not No. Andover MA 01845 use the return ke City/Town State Zip Code Y� 2. System Owner: rab Same l Name renm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Ga ons 3. Component: ❑ Cesspool(s,) ❑ Septic Tank El Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes �No 5. Observed condition of component ped: All of this estimated information is non-rindog, valid only at the time of pumping. Not responsible beyond the date above. 6. System Pf pe y: Name Vehicle License Number Company P Y 7. Location where contents were disposed: S Bradford, MA 01835 See above er Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts 100 AnaoVeC a City/Town of No. Andover o 2 �p24 System Pumping Record APR 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. 2. System Owner: te6 Same A) J>, Name rim Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 3 J Z — 2. Quantity Pumped: Date Gallons 3. Component: ❑ Cesspool(s) Septic Tank ❑ Tiaht Tank ❑ Grease Trap .5 ) ,prOther(describe): 4. Effluent Tee Filter present? ❑ Yes, No If yes, was it cleaned? ❑ Yes No 5. Observed condition of compon nt pumped: OA aQ> All of this estimated informatio - indi nng, valid only at the time of pumping. Not responsible beyond the date above. 6. System Pumpe�i By: Y /V `� Nam Vehicle License Number Company 7. Location where contents were disposed: ewart's Receivin ilit , 20 So. Mill St., Bradford, MA 01835 See above Si nature 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 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 �a Important:When a®�® filling out forms 1. System Location: � pd on the computer, use only the tab key to move your Address cursor-do not No. Andover � MA 01845 use the return City/Town ` \Q State Zip Code key. 2. System Owner: Same �a IGfY J Name -- �+m 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) [�eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): - - -- --- - — ----- 4. Effluent Tee Filter present? ❑ Yes Eplqo If yes, was it cleaned? ❑ Yes E7-"No 5. Observed condition of component 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: NamA 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, / L use only the tab key to move your Address cursor-do not No. Andover ` `).� MA 01845 _ use the return City/Town Q Q State Zip Code key. F 2. System Owner: r� Same Name rim Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping l� z 2. Quantity Pumped: Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap [Other(describe): �1 U� ��4�� 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of compoon�entt pumped: v U� I,. All of this estimated information is non-binding valid only at the time of pumping. Not responsible beyond the date above. 6. Syste umped B Name 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 System Pumping Record•Page 1 of 1 t5form4.doc•11/12