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Home My WebLink AboutSludge, Septic Tank, and Grease Trap, - Septic Pumping Slip - 351 WILLOW STREET 9/6/2022 Commonwealth of Massachusetts RECEIVED W City/Town of No. Andover System Pumping Record SEP 0 6 2022 Form 4 TOWN OF NOR]H ANDOVER HEALTH 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, use only the tab key to move your Address cursor-do not No. Andover MA 01845 use the return CityTTown State Zip Code Y �1 2. System Owner: V� '.N Name iaam Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 8� �ZZ 2. Quantity Pumped: � Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): �✓v ��— ✓c�tf �� 3tJ, ��°� 4. Effluent Tee Filter present? ❑ Yes 1�-No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed con ition of component pumped: c � bservations are driver's opinion based on what he sees at time of pumping on the date above. 6. System Pumped By: Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic 58 So. Kimball St., Bradford,MA 7. Location where contents were disposed: Stewapo Global Environmerital, LLC, 20 So. Mill St., Bradford, MA 01835 'P Same 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 � Commonwealth of Massachusetts RECEIVED a1 W City/Town of No. Andover SEP o 6 2022 _ System Pumping Record TOWN OF NORTH gNDOVER Form 4 HEALTH 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, use only the tab /V v �I (Q 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: (0 Name �m Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping pat z� Z� 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): 4. Effluent Tee Filter present? ❑ Yes eo If yes, was it cleaned? ❑ Yes ❑ No 5. Observed ndition of component pumped: �9—do 1) Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. System Pumped By: Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic 58 So. Kimball St., Bradford MA 7. Location where contents were disposed: Stewa 's Global Environme LLC, 20 So. Mill St., Bradford, MA 01835 Same - 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 RECEIVED Commonwealth of Massachusetts SEp 0 6 2022 City/Town of No.Andover TOWN OF NOR TH ANDOVER System Pumping Record HEALTH DEPARTMENT 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 / �j off l 1 l0 6v key to move your Address cursor-do not use the return City/Town State Zip Code key. 2. System Owner: 11 Name Tartan Address(if different from location) No.Andover MA City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Da a 2. Quantity Pumped: Gallons�v 3. Component: ❑ Cesspool(s) ❑ Septic ❑ Tight Tank ❑ Grease Trap Lt� S f c/c�G`40 ✓ 0c`J Other(describe): 4. Effluent Tee Filter present? ❑ Yes � to If yes, was it cleaned? ❑ Yes ❑ No 5. Observed�7dition of component pumped: 6. System Pumped, / K) c•, Name Vehicle License Number Stewart's Septic 58 So Kimball St. , Bradford,MA Company 7. Location where contents were disposed: 20 So., ill St.,Bradford,MA ❑ems Signature of Haul r Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 RECEDED CN- Commonwealth of Massachusetts u w City/Town of No. Andover SEP 6 2022 System Pumping Record � „ OFr,o��+ANDCVEB DEPAF�MENT Form 4 G7M 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, �� wl f�G'W' j 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: Name ream Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 6�-4 1. Date of Pumping Date ---- 2. Quantity Pumped: Gallons '3600- � 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 J�J'No 5. Observed condition of component pumped: Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. System Pumped By: Name Vehicle License Number AS Development Corp. d/b/a Stewart's Septic 58 So. Kimball St., Bradford,MA 7. Location where contents were disposed: Stewart's Global Environmental, LLC, 20 So. Mill St., Bradford, MA 01835 Same 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 RECENLU Commonwealth of Massachusetts SE? o 6 2022 W City/Town of No. Andover TOWN OF NORTH ANDOVER System Pumping Record HEALTHOEPARTMENT 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 6' w,/t OVJ key to move your Address cursor-do not No. Andover MA 01845 use the return key. City/Town State Zip Code 2. System Owner: Name - ranm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date I ^ zz 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 ❑ No 5. Observed condition of compone//nt pumped: /v-zyl1 a/� Observations are driver's opinion Kaseeron what he sees at time of pumping on the date above. 6. System Pumped By: Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic 58 So. Kimball St., Bradford,MA 7. Location where contents were disposed: Stewart's Global Environmental, LLC, 20 So. Mill St., Bradford, MA 01835 Same nalkre of Ha Date Same Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 RECEIVED Commonwealth of Massachusetts City/Town of No.Andover SEP 0 6 2022 System Pumping Record TOWN OF NORTH ANDOVER Form 4 HEALTH DEPARTMENT �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 / � _�! 2-� key to move your Address cursor-do not use the return City/Town State Zip Code key. 2. System Owner: RA-.� //��-i Name reran 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: Halloos 6l 3. Comp ent: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): �lJ4 5 J�� 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 6-Dd 6. System Pumpe 'P2, �S Name Vehicle License Number Stewart's Septic 58 So Kimball St. , Bradford,MA Company 7. Location where contents were disposed: 20 S . i St.,6 adford Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 RECEIVED �L\ Commonwealth of Massachusetts SEP p 6 2022 City/Town of No. Andover System Pumping Record TCHE LTHDEPAR M N 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, 551 use only the tab VV v l�v key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. �11 2. System Owner: Name rears - Address(if different from location) CityfTown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping " �f 2 ZZ 2. Quantity Pumped: Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): S ag { N1C - 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. Sys m Pumped Na Vehicle License Number J& Development Corp. d/b/a Stewart's Septic 58 So. Kimball St., Bradford,MA 7. Location where contents were disposed: Stewart's Global Environmental, LLC, 20 So. Mill St., Bradford, MA 01835 S�A � Same dya�- ig ture of Hauler Date Same Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 RECEIVED Commonwealth of Massachusetts City/Town of No. Andover SEP 0 6 2022 System Pumping Record TOWN OF NORTH ANDOVER Form 4 HEALTH 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, 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. 0`-11 2. System Owner: V12L�l o, Name Address(if different from location) City/Tow- State, Zip Code. Telephone Number B. Pumping Record / 1. Date of Pumping Date Z _ 2. Quantity Pumped: Gallons 3. Comp nent: ElCessssp`o�oll(s_)� El Septic Tank ❑ Tight Tank El Grease Trap Other(describe): 4. Effluent Tee Filter present? ❑ Yes Er No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: / ( qa/ e� Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. Sys3tqw Pumped. Name Vehicle License Number AS Development Corp. d/b/a Stewart's Septic 58 So. Kimball St., Bradford,MA 7. Location where contents were disposed: Stewa 's Global Environment LC, 20 So. Mill St., Bradford, MA 01835 Same 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 Commonwealth of Massachusetts R�°EwEo w City/Town of No.Andover tiotiti = p6 a System Pumping Record SEP PNoovEa Form 4 WN OF 'Del)P SMENj �0 HEP\''N 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 use the return City/Town State Zip Code key. 2. System Owner: Name ie2m Address(if different from location) No.Andover MA City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 1 a — 2. Quantity Pumped: 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): S 1 U Gil 1C 4. Effluent Tee Filter present? ❑ Yes VNo If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: I e 6 � 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 /Vl0 SC-n -Ta11Q(� S/?/,a- 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 RECEwEc' u City/Town of No. Andover SEP o 6 202� ° System Pumping Record 4 Form OF NORTH ANDOV> P TOWN HEALTH 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, I use only the tab I w ((D Gt/ S"L N ) key to move your Address cursor-do not No. Andover MA 01845 use the return key. City/Town State Zip Code 2. System Owner: 2 I T (� Name ,aem Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping ZZ 2. Quantity Pumped: Date Gallons 3. Comp nent: ❑ Cesspool(Is),-�l� ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): 1Vd AAA ~ 4. Effluent Tee Filter present? ❑ Yes Z No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped.- Observations are driver's opinionVd2n<lwhat he sees at time of pumping on the date above 6. System Pumped By: 7-Cfr- n'c�< Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic 58 So. Kimball St., Bradford,MA 7. Location where contents were disposed: Stewart's Global Environmental, LLC, 20 So. Mill St., Bradford, MA 01835 Same ure o auler Date Same Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 DECEIVED Commonwealth of Massachusetts W City/Town of No. Andover SEp o 6 2a22 System Pumping Record WN OF NORTH jMENTER Form 4 T�HEpLTH DEPAR �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' VV/16W key to move your Address cursor-do not No. Andover MA 01845 use the return Cityrrown State Zip Code key. 41L� 2. System Owner: VL-u I� Name renm Address(if different from location) City/-Town State Zip Code Telephone Number B. Pumping Record ZZ 1) CQG 1. Date of Pumping Date — 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank 0 Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes 1� No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: Obbseer6��vations are driver's opinion based on what he sees at time of pumping on the date above. 6. System Pumped By: _ Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic 58 So. Kimball St., Bradford,MA t 7. Location where contents were disposed: Stewart's Global Environmental, LLC, 20 So. Mill St., Bradford, MA 01835 /'&5E C,aV7 (So 1Le� Same 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