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Home My WebLink AboutTight Tank, Sludge Tank, Eq Tank, Grease Trap, Septic Tank - Septic Pumping Slip - 351 WILLOW STREET 10/3/2022 �EpENEn Commonwealth of Massachusetts 41 _ City/Town of No. Andover pcT o 3�022 ?� System Pumping Record ��,ur;voRr�+�"°EN1 a Form 4 TObLG� HpEPAR G"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, �57' �/� (� C� use only the tab 'V 1 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 �n Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date Gallons 2. Quantity Pumped: -- 3. Component: ❑ Cesspool(s) ❑ Septic Tank [`fight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes [�J/No If yes, was it cleaned? ❑ Yes K=_"o 5. Observed condition of component p mped: 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: 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 �ECEIVEd Commonwealth of Massachusetts 320Z2 W City/Town of No. Andover p�Z o System Pumping Record a�Nouj�'R'I a Form 4 �p H�a`TH VVP 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. A�11 2. System Owner: Name mun _A 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. Component: ❑ Cesspool(s)n ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed c dition of component pumped: �d� ,7 Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. System Pumped B� 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;'Stewart;'s Global Environmental, LLC, 20 So. Mill St., Bradford, MA 01835 2 a/L Same 5;�'J C11-7 � Signature of Hauler Date Same Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc-11112 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts �E��►v�ti W City/Town of No. Andover ' W° System Pumping Record o�� p 32022 Form 4 Pt4o IN R HM ewe TOWN�?H QEPA TMENT DEP has provided this form for use by local Boards of Health. Other forms4ay 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, r7 WI e , 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. 00_� 2. System Owner: Vv—� Joy Name nam 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. Compo nt: ❑ Cesspool'(1s))�� ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): 5 �'" -jk 4. Effluent Tee Filter present? ❑ Yes E No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: o� Observations are driver's opinion sed 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: Stewart's Global Environmental, LLC, 20 So. Mill St., Bradford, MA 01835 Same ure auler Date Same Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 �ECE�vE� Commonwealth of Massachusetts City/Town of No. _Very'❑ TH A�DOVEB Y Pumping TOTH DEPARTMENT ° System Pum in Record HEAL 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, Ile 1,, use only the tab ! l�V key to move your Address cursor-do not use the return City/Town State Zip Code key. 2. System Owner: Name ra2m Address(if different from location) Al O Aza4 ll;o-i MA City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: t; lions v 3. Component: ❑ Cesspool(s) ❑]Sj�eptic/Tank ❑ Tight Tank ❑ Grease Trap 2/other(describe): 4. Effluent Tee Filter present? ❑ Yes �o If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 6. Syste W ped By: ❑ �� ❑�� Name Vehicle License Number Stewa vs Septic 58 So Kimball St. , Bradford,MA Company 7. Location where contents were disposed: 20 So.Mill St.,Bradford,MA 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 �E�E�vED W City/Town of No. Andover 3202� System Pumping Record Form 4 N Ur Nv�TH AND NTER M T�HEALTH DEPA�TME 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, 3 5-1 w,ff S4— use only the tab �py�/ 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 Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record G� �,n,, 1. Date of Pumping pate Z Z 2. Quantity Pumped: Gallon 5WO 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank Grease Trap {A ❑ Other(describe): 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. 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 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 (� City/Town of No.Andover ocT o 3 ZW - System Pumping Record TOWN OF NOE HRTMENTEFt Form 4 HEALTH D 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, he tab use onlythe tab key to move your Address cursor-do not use the return City/Town/T key. � State Zip Code 2. System Owner: ray Name ream Address(if different from location) , J No.Andover MA City/Town State Zip Code Telephone Number B. Pumping Record q 1. Date of Pumping Date / 2. Quantity Pumped: ---D� Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): f n 4. Effluent Tee Filter present? ❑ Yes VNo If yes, was it cleaned? ❑ Yes ❑ No 5. Observed ondition of component pumped: B� 6. System Pumped By: f Name Vehicle License Number Stewart's Septic 58 So Kimball St. Bradford MA Company 7. Location where contents were disposed: 20 So II t.,Bradfo , A igna ure of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11112 System Pumping Record•Page 1 of 1 RECENED Commonwealth of Massachusetts City/Town of No.Andover 0C1 p 3 2022 System Pumping Record NORTH ANDOVER TOwri CF o Form 4 HEAt_TH DEPARTMEN T 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 ( ( U -f-> key to move your Address cursor-do not use the return City/Town State Zip Code key. 2. System Owner: r� / Name rim Address(if different from location) No.Andover MA City/Town State Zip Code Telephone Number B. Pumping Record �e 1. Date of Pumping Date 2. Quantity Pumped: Gallo 3. Component: ❑ Cesspool(s) [j;-Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes P No If yes, was it cleaned? ❑ Yes !:4-No 5. Observed condition of compFr;W mped: 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 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11112 System Pumping Record•Page 1 of 1 RECEjVED Commonwealth of Massachusetts City/Town of No.Andover 0CT 3202 OVER ° System Pumping Record TOWN OF NORTH AND T Form 4 HEALTH DEPAFtTMEN 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 I `/V ( U'►� key to move your Address cursor-do not use the return City/Town State Zip Code key. 2. System Owner: rab Name ream 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): � 6 e= 4. Effluent Tee Filter present? ❑ Yes VNo If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 6. System Pumped OP "Name Vehicle License Number Stewart's Septic 58 So Kimball St. , Bradford,MA Company 7. Location where contents were disposed: 20 So. II St.,Bradford,M r r 9-"l ^�� Signature of 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 W City/Town of No. Andover pCj 3zo22 H a a System Pumping Record WNO tAop:V Form 4 10 41EA.- " 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 U" 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 - — r�m Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping - 1 2� 2. Quantity Pumped: w Date Gallons 3. Component: ❑ Cesspool(s)� El Septic Tank El Tight Tank El Grease Trap Other(describe): �—", '� S - 4. Effluent Tee Filter present? ❑ Yes al-N-o' If yes, was it cleaned? ❑ Yes ❑ No 5. Observed ondition of component pumped: G--&, 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' lobal Envonm@ntal,_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 RECetVeD Commonwealth of Massachusetts City/Town of No. Andover 32022 System Pumping Record 0 0 T la's° 'T M y Form 4 TON�A TVAOSPARTM�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 1 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: Name rerun Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2 2 " Z2i 2. Quantity Pumped: 3'wO c) Date Gallons 3. 70theronent: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap (describe): 4. Effluent Tee Filter present? ❑ Yes ENo If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: O O O� Observations are driver's opinion basAd o what he sees at time of pumping on the date above. 6. System Pumped By: 77�E ;�" C'k- 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 ature o auler 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 �ECE►vE�, _ City/Town of No. Andover ° System Pumping Record oC1 0 32022 r` Form 4 TH ANpOVEb 'fO�N OTH DEpAR-TMENT DEP has provided this form for use by local Boards of Health. Other forms may De 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, Jam' r 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. �I1 2. System Owner: V att /V �11" Name iron 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 Q Other(describe): S1 u d!�2 1�1 `Tci a✓f G 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. Syste umped By: / Name Vehicle License Number AS velopment 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 ,L\- Commonwealth of Massachusetts N City/Town of No. Andover 31p22 W° System Pumping ing Record 0 Form 4 TOW vEH N F tyOFPA"VEND ,.� HEAD-�H DE 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, 3�t yy t(I Oyf J I 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. r� 2. System Owner: aIe- W1 Joy _ Name --------- - -- — seem 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(sj ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Ob rved cgndition of component pumped: O� Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. System Pumped By: ame Vehicle License Number AS Development Corp. d/b/a Stewart's Septic 58 So. Kimball St., Bradford,MA 7. Location where contents were disposed: Stewaaarrt'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 taEGENEC, IL Commonwealth of Massachusetts 'ROOM City/Town of No. Andover ��Z p 32022 System Pumping Record A400\1F G Form 4 TO NV4 TH®EP�TMEN� 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 _ 01845 use the return MA key. City/Town State Zip Code t� 2. System Owner: � I / Name Address(if different from location) --— — — City/Town State --- Zip Code .� Telephone Number B. Pumping Record - 1. Date of Pumping Date 2. Quantity Pumped: I �Od 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: g0c Z Observations are driver's opinion based on what he sees at time of pumping on the date above 6. System Pumped By: 161a�0-n 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 a-vi ---SO 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