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HomeMy WebLinkAboutGrease Trap, Septic Tank, sludge tank - Septic Pumping Slip - 351 WILLOW STREET 7/3/2024 _ Commonwealth of Massachusetts City/Town of No. Andover JUL p 3 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 _ -- _ 351 Willow Street key to move your Address cursor-do not North Andover MA 01845 use the return - --- -- - — -- - key. City/Town State Zip Code �1 2. System Owner: V� Bake'N' Jo Name ----- -- -� SAME Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record YZ �.Zy In Gpi LX 5 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): - --- - - - --- Sludge 4. Effluent Tee Filter present? ❑ Yes [S No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: Sludge All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. Syste u ed By- Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Stewart's Receiving Facility, 20 So. Mill St., Bradford, MA 01835 See above of Hauler Date SAME Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts a1 !� City/Town of No. Andover System Pumping Record a � 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 351 Willow Street key to move your Address cursor-do not North Andover MA 01845 use the return --- ._ - - - ----- - -- - —- - ---- key. Cityrrown State Zip Code 2. System Owner: r� Bake'N'Joy-- ----- Name - - -- - --- SAME Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Datb 2. Quantity Pumped: tali rfs 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap Other(describe): -— l ---- _---- Sludge 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition oicomponent pumped: (�06 G^ Sludge All of this estimated information is non-binding, valid only at the time of Dumping. Not responsible beyond the date above._ 6. SysterTPumped 90 Name Vehicle License Number J&S evelopment Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Stewart's Receiving Facility, 20 So. Mill St., Bradford, MA 01835 _ See above _ Signature of Hauler Date SAME _ Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 To'6`p, of�11,c Lid Ar,"O." Commonwealth of Massachusetts City/Town of No. Andover JUL 0 3 2024 - System Pumping Record Form 4 ��` .•.a� _ye,,,�.�..�,.,�,� t� td P el:tL' �i� �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 Willow Street use only the tab - key to move your Address cursor-do not North Andover MA 01845 use the return 0hy—down State Zip Code key. 2. System Owner: 110 Bake'N' Joy _ _—_—.— Name ream SAME —. - --- — Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record ns�76 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap _ Sludge ❑ Other(describe): - —— 4. Effluent Tee Filter present? ❑ Yes=No If yes, was it cleaned? ❑ Yes El No 5. Observed copdition of component pumped: Sludge 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✓� ame Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service __- 7. Location where contents were disposed: Ste a Receivin F ilit , 20 So ill St., Bradford, MA 01835 See above �. ..�. Signature of Hauler Date __ SAME Signature of Receivingcility(Faor 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 Y 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 _ 351 Willow Street key to move your Address cursor-do not North Andover MA 01845 use the return key. City/Town State Zip Code V`R2. System Owner: � Bake 'N'Joy Name SAME - ----------._..----- Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record u c 1. Date of Pumping 6 1 2. Quantity Pumped: J a� Date Gallons 3. Component: ❑ Cesspool(s) FrSeptic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): - —- Sludge 4. Effluent Tee Filter present? ❑ Yes �o If yes, was it cleaned? ❑ Yes V;--Ao 5. Observed condition of component pumped: Sludge 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 J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Stewart's Receiving Facie,20 So. Mill St., Bradford, MA 01835 _ See above Signature of Hauler Date SAME Signature of Receiving Facility(or attach facility receipt) Date t5fonn4.doc•11/12 System Pumping Record•Page 1 of 1 An,dovet _�LN Commonwealth of Massachusetts �1 City/Town of No. Andover JUL 0 3 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 351 Willow Street key to move your Address cursor-do not North Andover MA 01845 use the return ----- --_--- - -_. .__ --- -- -- - -- -. -- - ---------- _ key. City/Town State Zip Code �1 2. System Owner: V� Bake 'N' Joy - - Name ---_ ---- � SAME ---- - — ---- --- — Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping — 2. Quantity Pumped: - Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): -- — _ Sludge 4. Effluent Tee Filter present? ❑ Yes Uj- No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed c ndition of component pumped: &—r/'(` 7.. __-Sludge 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 J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Stewa ' Receivin Facility, 2 o_ Mill St., Bradford, MA 01835 -- -- _J yL - -See above `� C Signature of Hauler Date SAME Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 T%.i �'► L Commonwealth of Massachusetts City/Town of No. Andover JUL 0 3 zon System Pumping Record Form 4 'eni a Ld 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 _ 351 Willow Street key to move your Address cursor-do not North Andover MA 01845 use the return - - - - ----- __-- —_---- --- ----- -- - - -- key. City/Town State Zip Code V� S" 2. System Owner: Bake'N' Joy Name -— ------ SAME Address(if different from location) — City/Town State Zip Code Telephone Number --------- -- - B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallon 3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): Sludd e_ 4. Effluent Tee Filter present? ❑ Yes 0--No If yes, was it cleaned? ❑ Yes B—No 5. Observed conditfhn of component pumped: Sludge All of this estimated information is non-binding, valid only at the time of pumpim_Not responsible beyond the date above. 6. System Pumped By: P 0 C- _ Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Stewart's Receiving Facility, 20 So. Mill St., Bradford, MA 01835 See above Signature of Hauler Date SAME Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 Town of Nod Andover Commonwealth of Massachusetts JUL 0 3 2024 City/Town of No. Andover System Pumping Record iL^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 — 351 Willow Street _ key to move your Address cursor-do not North Andover MA 01845 use the return -- ------ --- — --- -------- -- ---- -- -- key. City/Town State Zip Code 00--11 2. System Owner: VP" Bake Tr J y__ - --— -- - Name � SAME Address(if different from location) - — --------- — City/Town State Zip Code Telephone Number B. Pumping Record q 000 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): Sludge 4. Effluent Tee Filter present? ❑ Yes Yo If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: Sludge 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 Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Stewart's Receiv' acilit 20 So. Mill St.-,-Bradford, MA 01835 ---- --- --- -- - - ---- See above ,gnatur f Hauler Date SAME Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 I o,,.vn of NoM MUM'f Commonwealth of Massachusetts '!UL 0 3 2024 City/Town of No. Andover , - � System Pumping Record y p g 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 ------ 351 Willow Street key to move your Address cursor-do not North Andover MA 01845 use the return - - — - - - — - - key. City/Town State Zip Code 2. System Owner: r� Bake 'N'Joy - --- - -- ------- --- Name --- ------- SAME Address(if different from location) Citylrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping r Z 2. Quantity Pumped: Date Gallons 3. Component: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): - Sludge 4. Effluent Tee Filter present? ❑ Yes e/No If yes, was it cleaned? ❑ Yes E No 5. Obs rved condition of component pumped: }� Sludge All of this estimated information is non-binding, valid one at the time of pumping. Not responsible beyond the date above. 6. System Pumped By: 0 �Vvi CV1 c Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Stewart's Receiving Facility, 20 So_._Mill St., Bradford, MA 01835 See above Signature of Hauler Date SAME Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 Tav4��� ®1 ` t►1 Peraov�r �L\ Commonwealth of Massachusetts City/Town of No. Andover lUL 0 ,1 202� System Pumping Record Form 4 ,,,.�,� -, .��, �€ r ► _ H 0 L 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 _ 351 Willow Street key to move your Address cursor-do not North Andover MA 01845 use the return -- -- -- - - - - — ---- - key. City/Town State Zip Code d--1 2. System Owner: V� Bake'N' Jam__ Name - --- �+� SAME 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): — ------- --Sl�- 4. Effluent Tee Filter present? ❑ Yes SAo If yes, was it cleaned? ❑ Yes No 5. Observed con ition of component pumped: ��` Sludoe 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 J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Stewart's Receiving Facility, 20 So. Mill St., Bradford, MA 01835 See above Signature of Hauler Date SAME Signature of Receiving Facility(or attach facility receipt) Date t5fomi4.doc•11/12 System Pumping Record•Page 1 of 1 Town of Niodh Andover Commonwealth of Massachusetts City/Town of No. Andover JUL 0 3 2024 _ System Pumping Record Form 4 A�, .r , ,a ► e�3t 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 351 Willow Street key to move your Address cursor-do not North Andover MA 01845 use the return - -- - -- State ate - - -- key. City/Town Zip Code 2. System Owner: � Bake'N'Joy - - Name SAME Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record v 1. Date of Pumping 2. Quantity Pumped: J-- -� Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): - ----— --- - Sludge 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: / r7� 0,� Sludge All of this estimated information non-binding, valid only at the time of pumping. Not responsible beyond the date above. 6. System WMpBy: / Name Vehicle License Number J&S Dev pment Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Stewart's Receiving Facility,_20 So. Will St., Bradford, MA 01835 See above Signature of Hauler Date SAME Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 ol r. Andover , i��t Commonwealth of Massachusetts �1 Z City/Town of No. Andover -- System Pumping Record - Form 4 He�sb�"t 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, use only the tab _ 351 Willow Street - key to move your Address cursor-do not North Andover MA 01845 use the return - --- --- --- --- -- - - -- ---- -- - -- -- key. City/Town State Zip Code 2. System Owner: Bake 'N' Joy Name SAME -- --- - - ---- Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2 2. Quantity Pumped: dons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): — ____. -____ Sludge__ 4. Effluent Tee Filter present? ❑ YesjQ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: C " -Crr^ c/ Sludge 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 J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Ste a 's Receiving Facilit So. Mill St., Bradford, MA 01835 r See above 7 O� Signature of Hauler Date SAME _ Signature of Receiving Facility(or attach facilfty receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 10,�Ivl°� 10 ��to Commonwealth of Massachusetts 0� 3 2oti4 City/Town of No. Andover ,me�rt -- System Pumping Record Form 4 kAe 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 -_ 351 Willow Street key to move your Address cursor-do not North Andover MA 01845 use the return -- - -- - --- - --- - — key. City/Town State Zip Code 11 2. System Owner: Bake'N' Jo Name - - � SAME _ Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping -- 2. Quantity Pumped: QD Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes(EI-No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: ,:;7__t?c' y Sludge All of this estimated information is non-binding, valid only at the time ofpumping. Not responsible beyond the date above. 6. System Pumped By: 6h� S_ CO Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Stewart' Receiving Fa ilit , 20 Mill St., Bradford, MA 01835 t _ See above ` Signature of Hauler Date SAME_ Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1