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HomeMy WebLinkAboutsludge tank, tight tank, eq pancake batter grease trap, septic tank - Septic Pumping Slip - 351 WILLOW STREET 5/6/2024 Commonwealth of Massachusetts = City/Town of No. Andover I'MY 06 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/I I(O 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 —- -- — - teem Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping -- h-V- 2. Quantity Pumped: - -- Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap 1-S7/6/d Other(describe): _-�- 4. Effluent Tee Filter present? ❑ Yes CS,_No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed c ndition of component pumped: G C(7� 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: fi - - `� ll', A` ru)e'0z:3- '�'s 0 Name Vehicle License Number Company 7. Location where contents were disposed: Stewa Receiving Facile, 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 MAY 0 6 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, (l D use only the tab Vu 111 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 Name nem Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date - -- 2. Quantity Pumped: Gall nss 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap [Other(describe): -51� � 4. Effluent Tee Filter present? ❑ Yes �/No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: All of this estimated information is non-binding, valid only at thd time of pumping. Not responsible beyond the date above. 6. System Pump d B Name ,, n. Vehicle License Number Company`J`I��xivr�+t 7. Location where contents were disposed: Stewart's Receivin cilit , 20 So. Mill St., Bradford MA 01835 See above na f 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 MAY 0 6 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, //I I' /1 > 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: Same Name - �n Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping O Date 2. Quantity Pumped: �7S Gallons 3. Component: ❑ Cesspool(s) El Septic Tank El Tight Tank El Grease Trap [`f Other(describe): �/ `7-{` '✓ — - 4. Effluent Tee Filter present? ❑ Yes E2/No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: zs!/ycbe__� 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 Name Vehicle License Number Company 7. Location where contents were disposed: Stewart's R eivi✓g Facility, 20 So. Mill St., Bradford, MA 01835 See above gnature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date System Pumping Record•Page 1 of 1 t5form4.doc•11112 Commonwealth of Massachusetts _ W City/Town of No. Andover MAY 0 6 2024 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�3S� � t((v 6,) -C,1- 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 e N �a Name nem Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record � _ y 1. Date of Pumping Date ( -� I-- 2. Quantity Pumped: Gallons?C, 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap c® Other(describe): -- --- - - 4. Effluent Tee Filter present? ❑ Yes ®-No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed c dition of component pumped: C� 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✓. � r l r�r L 'Name Vehicle License Number Company 7. Location where contents were disposed: Stewa ReceivingF cilit , 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 i .� �L\ Commonwealth of Massachusetts W City/Town of No. Andover MAY 0 6 2024 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, � �� d6(4 S� 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: reb ( n) r J Same Name ream Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 2 �d 1. Date of Pumping Date 2. Quantity Pumped: Gallons� 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): 'S/`J 0 A::� - 4. Effluent Tee Filter present? ❑ Yes [®5 No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: Gry 0(-;6 ) 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: Named !� Vehicle License Number Company 7. Location where contents were disposed: Stewart',VRecpiving Facility, 20 So. Mill St., Bradford_, MA 01835 V/ztC/ / �.J G 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 MAY 0 6 2024 wM 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 _ ux /V `J l: 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 - - - - ranm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping LI Z 2. Quantity Pumped: Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): SIU (19e 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition 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. 7Stem Pumped By: 6 Name Vehicle License Number Company 7. Location where contents were disposed: Stewart's Receiving Facility,_20 So. Mill St., Bradford, MA 01835 11t4a Sa`n -TcY�Q'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 s71 Commonwealth of Massachusetts _ W City/Town of No. Andover MAY 0 6 2024 System Pumping Record Form 4 n�K7 M Health 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 s Vv I j O(,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: Same JO IL Name ream Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 2 1. Date of Pumping - Z - 2. Quantity Pumped: lo J Date — Gallons 3. Component: ❑ Cesspool(s) ❑ Septic TanK ❑ Tight Tank ❑ Grease Trap ffOther(describe): - 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition 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. Sy m P mped : N,tl Vehicle License Number Company 7. Location where contents were disposed: Stewart's ReceivingFacility,_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 MAY 0 6 2024 System Pumping Record iGM 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 J l 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� � i --- Same N I `Joy _ Name stun Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date Z - 2. Quantity Pumped: ons I � — 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap [Other(describe): S) U A 9 e 4. Effluent Tee Filter present? ❑ Yes [�No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 0o b 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: /�s©Y) -j.,n P 3 Name Vehicle License Number Company 7. Location where contents were disposed: Stewart's Receiviq _Faciliq, 20 So. Will St., Bradford, MA 01835 0r PS 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 C i W City/Town of No. Andover MAy 0 6 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, 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 r� 2. System Owner: y, _ r � r � �• Same �GC.Y /V Jd Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 7 z s� 1. Date of Pumping --- 2. Quantity Pumped: Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank [-Tight Tank ❑ Grease Trap ❑ Other(describe): --- 4. Effluent Tee Filter present? ❑ Yes EKNo If yes, was it cleaned? ❑ Yes ;�KNo 5. Observed condition of com nent 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: fZ Vn ►"� Name Vehicle License Number Company 7. Location where contents were disposed: Stewart's Receiving Facilit�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 MAY 0 6 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, use only the tab key to move your cursor-do not use the return GtylTown State Zip Code key. 2. System Owner: _ -Lie - - `-)U Name rsam Address(if different from location) No Andover MA 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): 9-q W­ —�� 4. Effluent Tee Filter present?\ Yes ❑ No If yes, was it cleaned? Yes ❑ No 5. Observed condition of component pumped: �' Clrv�/Il AA 6. Sy t P ped f < < u �j44 Name vehicle License Number Stewart's Septic 58 So Kimball St. , Bradford,MA Company 7. Location where contents were disposed: 20 So.lVWStj3radforcjMA �� 92� 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 I System Pumping Record MAY 0 6 2024 Form 4 '7M 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 35( 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 raun Address(if different from location) City/Town State Zip Code Telephone Ntmber B. Pumping Record 1. Date of Pumping Dar 2. Quantity Pumped: llonns 3. Component: ❑ Cesspool(s) ❑ Septic Tank fight Tank ❑ Grease Trap ❑ Other(describe): - - - - 4. Effluent Tee Filter present? ❑ Yeso If yes, was it cleaned? ❑ Yeslo 5. Observed condition of component p ed: All of this estimated information is non-bi I A, valid only at the time of pumping. Not responsible beyond the date above. 6. Syste umpe�y:� Name Vehicle License Number Company 7. Location where contents were disposed: Stew cilit , 20 So. Mill St., Bradford, MA 01835 See above ignature of Haul Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1 Andover Commonwealth of Massachusetts W City/Town of No. Andover MAY p 6 2024 System Pumping Record Form 4 s ►aitment 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 __ __ ��t __ __ ✓ key to move your Address cursor-do not No. Andover _ MA 01845 use the return City/Town State Zip Code key. 2. System Owner: reb Same 3!y tAl► f(ow S� Name �sn Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record T2- 1. Date of Pumping Da e q 2. Quantity Pumped: 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 comppnent pumped: All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. Systerq pumped By- Name �J 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 T®wn ; tol lo�.h Andover L _ Commonwealth of Massachusetts City/Town of No Andover MAY 0 6 2024 System Pumping Record Form 4 He�-1 i`� Department 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, / , / `O W J� use only the tab ��! /fit/ key to move your Address cursor-do not use the return key. City/Town State Zip Code �1 2. System Owner: ✓ Name ranrn Address(if different from location) No Andover MA 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 [l No If yes, was it cleaned? ❑ Yes � ryo 5. Observed condition of componer}t pumped: 6. System Pumped By: Name Vehicle License Number Stewart's Septic 58 So Kimball St. , Bradford,MA Company 7. Location where contents were disposed: 20 So.Mill St.,Bradford,MA Signatu auler- - 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 u System Pumping Record MPS 6 Form 4mer� 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, 71 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 �1 2. System Owner: V r Same - - It% �O Name ratan Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record t1 1. Date of Pumping 2/ 2 -1 2. Quantity Pumped: 3900 Date Gallons 3. Component: ❑ Cesspool(s) El Septic Tank ❑ Tight Tank ❑ Grease Trap [Other(describe): 24e' - 61 4. Effluent Tee Filter present? ❑ Yes to If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped:} ��(lU All of this estimated information is non-binding, valid only at thklWne of pumping. Not responsible beyond the date above. 6. System Pumped By: :M!g 1A:t _ Name Vehicle License Number Company 7. Location where contents were disposed: Stewart's Receiving Facility, 20 So. Mill St., Bradford, MA 01835 See above i are of uler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1