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Home My WebLink AboutMiscellaneous - 466 WINTER STREET 4/30/2018 (2)[90 o -s 1N�1 • O ............. ................ dry �.................... ....................................................................................................... ............................. Learn more about the Lakota (Sioux) culture at stio.org/culture i Stewart's Septic Service ❑ Andover Septic ❑ Stretham hill Septic (978) 372-7471 . (978) 475-2593 (603) 772-5548 s 58 South Kimball Street, Bradford, MA 41835 �te of,�vi�ce� PAY FROM THIS BILL ❑ Roto -Ram (978)452-9022 Custom' me{ g _ _ t Reg• N re of Service Reg. Maint. ❑ Emergency SrL tion: f t ( 7 e� r t Septic Tank Pumping and Cleaning ❑Day ❑Night Phone: Tone the Right Way" Contact: Not Responsible for Covers Billing Address:. or rrigation Systems �Q • tJc? v' Special Instructions p Completed ❑: incompleted Reason Per AM/PM P Services Rendered _ �_.G'�Gi •.tom' Vacuu;$urnping Septic Tank Observations Good Condition Drain Cleaning ❑ Main Line ❑ Drywell Leechfield Runback ❑ Toilet Bowl ❑ .Leech Pit/ Overflow ❑ Riding High ❑ Kitchen Sink. ❑ D -Box (liquid level) ❑ Bathtub / Shower ❑ Pump Chamber ❑ Full to Cover ❑Vanity ❑ Grease Trap ❑ Excessive Solids ❑ Floor Drain ❑ Catch Basin Top / Bottom ❑ Vent ❑ Portable Toilet ❑ Use No Powdered Soap ❑ Sewer Jet ❑ Other ❑ Heavy Grease ❑ Other Qry: Size: ❑ Under 1000 gallons rW 1000.gallons ❑ 1500 gallons ❑ Roots ❑ Suggest Electric Rootering Footage: ❑ 2000 gallons ❑ 30(0 gallons ❑ . 4000 gallons ❑ Van Called ❑ 5000 gallons ❑ Other ❑ Other Misc. ❑ Digging Charge * ❑ Backhoe ❑ Inspection ❑ Location ftAn. ❑ Consultion hrs. ❑ Certification: P/F ❑ Service Call ❑ Estimate Reason: ❑ Labor ❑ Portable Toilet Rental ❑ Pump Repair ❑ Waiting Time ❑ Baffle ❑ Repair ,,,!..,,Digging Charge is Per Driver __ w , .. .. .:.; -:., . ,:. ❑ .Other 'Discretion _ _ Description of work Recommendations Terms of Payment Parts Vacuum Pumping Drain Cleaning Yr. Month Yr. Month PAYMENT DUE IN FULL UPON COMPLETION Tax Discount Terms & Conditions ❑ Cash Check ❑ Credit Total 1. Not responsible for damage beyond curb tine. 3. 1.5% per month will be charged to accounts past due. 2. All complaints shall be reported within 48 hours. n 4. The purchaser agrees to pay all cost of collection. Stewart's Septic Service ❑ Andover Septic ❑ Stratham Hill Septic ❑Roto-Ram (978) 372-7471 (978) 475-2593 (603) 772-5548 (978) 452-9022 58 South Kimball Street, Bradford, MA 01835 r7K 1- PAY FROM THIS BILL ❑ Main Line i r Name!:1 C�-- ❑ Riding High 0 Reg. ❑ N/G Septic Tank Pugtping and Cleaning "Done the Right Way" Not Responsible for Covers or Irrigation Systems Nature of Service T�Reg. Maint. ❑ Emergency ❑ Day 0 Night Location: C Phone: Contact: - Wdress: ❑ Floor Drain Zip: v ' k s r t' f Special Instructions O Completed Per. _ AM/PM Services Rendered V uum Pumping Septic Tank ❑ Drywall ❑ Leech Pit / Overflow ❑ D -Box ❑ Pump Chamber ❑ Grease Trap ❑ Catch Basin ❑ Portable Toile J" ❑ Other Qty' - Size: ❑ Under 1000 gallons ❑ 1000 gallons ❑ 1500 gallons ❑ 2000 gallons ❑ 3000 gallons ❑ 4000 gallons ❑ 5000 gallons O Other Misc. ❑ Digging Charge * ❑ Ba ❑ Location n•/'n• ❑ Con ❑ Service Call 0 Esti ❑ Labor 0 Po 0 1�YaiGngSimQ._ ❑ Baffl Digging Charge is.Per Driver Discretion Back Description of work Ob tions Drain Cleaning 13 Good Condition ❑ Main Line ❑ Leechfield'Runback ❑ Toilet Bowl ❑ Riding High ❑ Kitchen Sink (liquid level) ❑ Bathtub / Shower . Full.to Cover ❑ Vanity ❑ Excessive Solids ❑ Floor Drain Top/ Bottom ❑ Vent ❑ Use No Powdered Soap ❑ Sewer Jet ❑ Heavy Grease ❑ Other ❑ Roots Footage: O Suggest Electric Rootering L3 Van Called L) Other n'►ate rtable ❑ Inspection sultion hrs. ❑ Certification: P/F Reason: Toilet Rental ❑ Pump Repair e ❑ Repair. ❑ Other Recommendations U Terms of Payment Parts Vac ding Drain Cleaning PAYMENT DUE IN FULL Yrs Month , Yr. Month UPON COMPLETION Tax TdAs-8r onditions 0 Cash O Check ❑ Credit Discount Total 1. Not responsible for damage beyond curb One. 3. 1.5% per month will be charged to accounts past due. 2. All complaints shall be reported within 48 hours. 4. The purchaser agrees to pay all cost of collection. 17 A Lai lvuvvtK MAS ACNUSETTc o rtEC 0 5 2008 OF NORTH ANDOVER U-H53Z-P 9TVF—AIT a .o / IIOr IAA(0%In C ollry 1 r'u11{)1lly FQyora z5 08 i Oa;e o! Pumpinp' - )': �Q 0'5.9.^1 -------------------- .) '.'. a ll ^ la ^"" 61 I ` "�41✓ (mac �L/��r n ��Q. Alo • '�:'�..sv ;'•1;, ,�:, S , . , , spam .o v C� /WQrµ4 (1114Vf�r'rnitran'buUcn 1 r'u11{)1lly FQyora z5 08 i Oa;e o! Pumpinp' 4- Ehluenl Toe Flllo(P(gyent? h Y09 _ C0�46ri'P(:9Yl,m:,.�,'. i ' SYPim od 8 p ' .J.,�.r I ! Y^ r[' ,'U� 1/II •('{ 41 d(i\ ' 11� lig U � �' 1' 1 on.WWQ co�lanla'wara dl9poC . ,.: {', .1. , '., 011.,`', r.•• , 1w -..'.I . .,1rNx.ma,J,gov/de^elar/epproYaJa/Iblorm�.r, maln9�vc1 BOl!C Tants 77 i lllzslnP -- 4- 0- _T• - )': �Q � Other (doscriba•�: — 4- Ehluenl Toe Flllo(P(gyent? h Y09 _ C0�46ri'P(:9Yl,m:,.�,'. i ' SYPim od 8 p ' .J.,�.r I ! Y^ r[' ,'U� 1/II •('{ 41 d(i\ ' 11� lig U � �' 1' 1 on.WWQ co�lanla'wara dl9poC . ,.: {', .1. , '., 011.,`', r.•• , 1w -..'.I . .,1rNx.ma,J,gov/de^elar/epproYaJa/Iblorm�.r, maln9�vc1 BOl!C Tants 77 i lllzslnP -- 4- 0- _T• K•I:V 111:'1,_,�. "M .ti -.. . it,,,5:' Y L'r. 11' ••I�l::v \v{ y.1" •lk rjU��li}!, j1r1r•; �: •t`I ,1•'.f1':'�Y!;('1: .. ';•�'.\ {r1 'i''v:IrK ��, 1..rLr far,' �� .:.,. 1; v+ � n.li�.A:4• y,'.. t DER haj �.. EP..has provided thli form for use by ba:ubmlged tv the.local'Board of Hea A:..Facility Inforf4flon J,,Whan� tQP,,�Lr t ; ;1; . System LooatJonr` only the tab key Address to move your ausor, • do •not . — . �All I/Al, usi key u ,;1, �;:;!;:;,, :: `' • :,':',�'{:;I�;,::T : ; .. r: ; .. .�. L• It�.J!,.ii �(I .,r ,. 1,t •'1 tm Ow , a ner'.,, 'i it :l i' :fiVl',;: �•,Si i.!, / .�•! , State ACHUSETTS�:``' System Pumping Record rn;;s: rlty, 1;11— .,Naw . ,I).:'�,. :•• .r', . ;`; 77- .. . Address (If different from'locatlon) 041T•,ow,n. Telephone Number �• r ate of Pumpinq''1.�Date �7 2' Quantity Pumped: Ypa pf ;;,:•...; :.system; ; Cesspool($) Septic Tight Tank .,.Other (describe); "` 4T:;Fllte � se? ] Yes t.o ❑Yes ❑ Nopee if yes was It oleaned? .'If:•'i.. ' :6T:�',co�dlacn'orsy$t j}�r�'�',��.'t'� • �,a•. � ,•�:�f :y.• `.'�rl''y'va�:fi•;V%lirJr :'tt'1 r�.. i,.,rl�'1%In'lJ ;rr•�,f�••. .. � '.w• r �. , �v., �••:t�/'!�i:+'ct�.'j"!,';Y�trl •I,�f;�i:r:�4�ry,'i•; ,•'r:i � i3 i "� ,�+•' •.- ' ;i•�+��•if1:�Yn. vV:�!�.b1�:�r{:l. !l (',. �I.:. ,.:�., Pumped rii"'• . j'aj:`a' 7 ..ijla'•J'Yy r1'v' fN�4';r•-�.. Vehicleconi umber ' �' `�.'i' '' %ti 1. v, \: y,./Ylulrf�,/i,, (7�1, ,S',r. 1'`�''I}'h'••I t�'Y!' . •+.o; :'r•Y"Y.i'/•i•. r•.r i 1 Tq .v+n %• (JJy}��}yr``))!. �r.li °Yl••' ;•lilj 'i.' 'i,i•Ui,ii{t d..1•y..e,"••HYd 1�! ��k}4J�•.v�r. ;fir:•,AYtt�TTT„l4':}.Oay��: 1, ... F.� L 1: Lfl,f;•. ;.. ;�i'.. o here; oonteritS eke : deposed: 'r>�:.;= , ::;!:. r.::;:;;r�t. •�:....;:•.{,. .r•; ,'sic ; v.'i.::' �: ':.S,�i"' ` :l : tire. �k /y/V •'�� .;i��'`''a 'l. ti�.'i%IN:�"'•`�:://:, '':T,' ��,�. ;�,rw; ,••., ivty�. • is:i,• �,t{ .. i.,; n r1'p t�l•y;.x„( ,� � i'y' r !Z/ „ 9 .... �' ;' X. •;.:.;?;.S .a��reolHauier;;µ�,:;.;,y.;.�,•,,.:r..,:..: ti : httpJ/rvivw,massr8ov/da�rvatet/app rovaJs/t5forms,htm#Inspect Date • CSforrM.doa;08IQ3 ,_ , rSYCOm Pumping Racord Page t of , � Commonwealth f Mas achusetts City/Town of ro d��/'�-�' SystemPumping 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. CitylTown State Zip Code State Telephone Number Zip Code B. Pumping Record 1. Date of Pumping = 2. Quantity Pumped: ' _ " Date Gallons 3. Type of system: ❑ Cesspool(s) N/Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: If yes, was it cleaned? ❑ Yes ❑ No 6. Synmv mPu ped By: __ Name Vehicle License Number Stewart's Septic Service Company'„ w9 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 (l�C Signature of Receiving Facility Date Date System Pumping Record • Page 1 of 1 A. Facility Information Important: When filling out forms 1. Syst Location: on the computer, LL use only the tab _ key to move your Ad es cursor - do not O use the return key. — City/Town VQ2. System Owner: �Mx IL Name iennn Address (if different from location) CitylTown State Zip Code State Telephone Number Zip Code B. Pumping Record 1. Date of Pumping = 2. Quantity Pumped: ' _ " Date Gallons 3. Type of system: ❑ Cesspool(s) N/Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: If yes, was it cleaned? ❑ Yes ❑ No 6. Synmv mPu ped By: __ Name Vehicle License Number Stewart's Septic Service Company'„ w9 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 (l�C Signature of Receiving Facility Date Date System Pumping Record • Page 1 of 1 19 Commonwealth of Massachusetts 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 on the computer, use only the tab key to move your cursor - do not use the return key. 2 maun System Location: 1 � G Address No Andover City/Town n lef 'i�,Vee � System Owner: n Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system ❑ Other (describe) Ma State Zip Code State Zip Code `7 t -7 9 J Telephone Number f/ /)z / 1- Date 2. Quantity Pumped: l06 Gallons ❑ Cesspool(s)Septic Tank El Tight Tank El Grease Trap 4. Effluent Tee Filter present? ❑ Yes IK, No 5. Condition of System: 6. System Pumped By: Name Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradfol Of If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number�� u 0 CRTH ANDOVER -TOWN OFA=PARTMENT Ma 01835 Date Date t5form4.doc• 03/06 --% System Pumping Record • Page 1 of 1 Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: k)n Gallons 3. Type of system: ❑ 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. Condition of System: 6. System Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: t Plant, 20 So. Mill Bradford, Ma 01835 Signature of Pauler Signatu4ef of Receiving Facility Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts RECEI'VED d City/Town of North Andover m a System Pumping Record `W 5� Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be use--d-,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, qV0 �] use only the tab key to move your Address cursor - do not North Andover Ma 01845 use the return key. City/Town State Zip Code rab 2. System Owner: j {� Xpe 1\ Do, mrom Name Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: k)n Gallons 3. Type of system: ❑ 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. Condition of System: 6. System Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: t Plant, 20 So. Mill Bradford, Ma 01835 Signature of Pauler Signatu4ef of Receiving Facility Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 .C-\ Commonwealth of Massachusetts City/Town of No.Andover a W° System Pumping Record Form 4 N SVe e Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. VQ IkIf rcnen 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 fr um ing date in accordance with 310 CMR 15.351. h. NAMI& A. Facility Information LTOWN a z 1. SystemLocation: ORTH ANDOVERY�_P� d�pARTMI?NT Address No.Andover Ma 01845 City/Town 2. Systemni Name Address (if different from location) State Zip Code City/Town State Zip Code B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Other (describe) Telephone Number I coo � Date 2. Quantity Pumped: Gallons ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap 4. Effluent Tee Filter present? ❑ Yes No 5. Condition of System: If yes, was it cleaned? ❑ Yes ❑ No 6. yste mped y: me Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 , C ho Sig a f auler Si a wing Facility Date ' / _ % Date II Y�) t5form4.doc• 03/06 — System Pumping Record • Page 1 of 1 0` , i j STERART'S SEPTIC TANK SERVICE 47 RAILROAD STREET BRADFORD, MA 01835 978-372-7471 mm OF O C fo b e--r- /a5 t3ock-y Brob e X0,3 j® ia-11, nL 76 TUC leer L166 Burn - r 3r i / a /%'T p, c /q/1 l i-2?dd,)c l< lG t7 / / 17 �- / her�y 9 /-, % (-C C5 -w(, e - �� z' q14 Tc-� f /noo /e)a6 1 Std 150 b'S aff .1. 57. '•I16?s L'T o2Ac4zt_7- 3 � 7 1 ) r i 8 cA4, �� S�PrK-TA►,1k Ili TzeE y r— IN f 100 anw P" at 110 a �'� m.n•.�G;y �� 'mmesn^1r�Z� • ��o a :oseoh :. barbaoallo. r.s. I westward circle no. readina_m9ss. TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER & ADDRESS do, C 'ndc)w'L) { SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: L ij.eld ( QUANTITY PUMPED GALLONS CESSPOOL: NO V YES SEPTIC TANK: NO YES i/ NATURE OF SERVICE: ROUTINE i/ EMERGENCY OBSERVATIONS: GOOD CONDITION ✓ HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) f - DEC - 7 20Ot T O Wi' 0 F!`,' 0 R T 1-1 A ,N' D O r� S Y ST E m 1l u iim p l INI C ;'-HEALTH ctrl U R & .�L)D'RCSS - _ 5 200 6��J6 IV6� WY! N C0 L a UU No YES SCP"" C''I"A ;r: KC U SCR` ICF ROUT1NL Etil :ISG :'' C. Ul" 10N r �UC�S -- EXCESSIYE SOLIDS SOL D CARRY0vCR C A C H F 1 FLOODED - - O+�HER (EX.f a'� --- ^ f' 1 1' CD BY nSFC)ZRED Tu DATE OF PUMPING 0 6- QUANTITY PUMPED CESSPOOL N0 --k1- iflS SEPTIC TANK NO YES NATURE OF SERVICE; ,ROUTINE /EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN LACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDCARRYOVER OTHER EXPLAIN SYSTEM PUMPED BY -AZ414,01- 0 T-0 TOWN O�FNORTH AN . DOVE,k U A ['F SYSTEM! PUMPINQ RF.COR.L) SYSTEM OWNER & ADDRESS 7 D e z RECEIVED NOV - 3 2004 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 0 T 0 1 bM LOCATION 0 DATE OF PUMPING:_ A .—QUANTITY PUMPED:, 0 CLSSPOOL: NO .. YESSOP(ic Tank: NO, YES NA FURS OF SERVICE: OBSERVATIONS: WOD CONDITION ../PULL 'F() COVER HEAVY OREASEBAFFLES IN PLACE,ROOTS LMCKKIELD RUNBACK BXCESSIVE SOLIDS ...... FLOODED SOLID CARR YOVER,__.... 0TffER EXPLAIN SY"tom Pumpod by �'UMMENTS. Q.uNIhNTS ;: �N.. '"• tri .M i:a" K:.' 'ii.a�k, " r • . .i'�r'1i •" " d�7iIG:3:ii,�+�Yw11i% �` 4'(�:'. ,. "ST*Ei '1 PUMPINQ Rp �O � v iYSreM QR )vpuc 1'cni n; Hn rvKU Or s�RY►c�8; W vri OOOD RMY CO�pI38IU FVLL I'V holo, RO'OT\3.. �WKI'1Nrl..o �IVtYQY�K meR �XP��IN t'moom VMM!~Ni�. UH I'M tX�Nyr XKbU I1' t r REC DEC 0 6 2005 OF NORTH ANDOVER LTH DEPARTMENT Commonwealth of Massachusetts City/Townl''of NORTH ANDOVER. M System Pumping Record -.Form4- SSACHUSETTS DEP has provided this form for use by local Boards of Health TherS=ystOULP —Ping R cord mu,, be submitted to the local Board of Health or other approving uthority. A. Facility Information Important: TOWN OF NORTH ANDOVER When filling out 1. System Location: - HEALTH DEPARTMENT forms on the computer, use only the tab key . Address—_______._..___,__..CQ •._ . ( — ----- - - - -- - to move your cursor - do not Stat��_.�— use the return City/Town key. Zip Code y 2, System Owner; Name Address (if different from location) City/Town ------ _--------- State _------- _._.. ip Code " Telephone Number -'-- - B. Pumping Record 1. Date.of Pumping Date �-_ 2 uantity Pumped: Gallons _-_.--- - 3. Type of system: ❑ Cesspool(s) 2 Septic Tank ❑ Tight Tank ❑ Other (describe): 4, Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? El Yes ❑ No r. 5. Condition of System: Sy em Pumped By: Name �--- _— Vehicle License Number - Cyt 11 .,rte/��• Company .7. Location wherecontents were disposed: J Si ature of Hau- http://www.mass.govi/dep/water/ provals/t5forms.htm#inspect t5form4.doc- 06/03 System Pumping Record - Page t of t Important When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. It til Commonwealth of Massachusetts - City/Town of System Pumping Record DEC 2010 Form 4 ANDOVER RTMENTDEP has provided this form for use by local Boards of Health. Other forms may 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 1. System Location: q(00 Address North Andover Cityrrown 2. System Owner. Name Address (if different from location) City/Town ma 01886 State Zip Code State Telephone Number B. Pumping Record 1. Date of PumpingI ! —�—`— 2. Quantity Pumped: ❑ Cesspool(s) Septic Tank ❑ Tight Tank 3. Type of system: ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: Zip Code 16C)C) Gallons ❑ Grease Trap If yes, was it cleaned? ❑ Yes ❑ No OCL 6. Syr Pumped §h -p CA H U1, 07, NameVehicle License Number Stewart Septic Service 761Ltion where contents were disposed: arts Pre treatment Plant 20 So. Mill St Bradford Ma 0 1835 of Hauler Signature of Receiving Facility Date t5fom4.doc- 03/06 System Pumping Record • Page 1 of 1