The URL can be used to link to this page

Home My WebLink AboutGrease Trap, Sludge Tank - Septic Pumping Slip - 351 WILLOW STREET 1/5/2023 Commonwealth of Massachusetts RECEIVED u W City/Town of No. Andover System Pumping Record JAN 0 5 2023 Form 4 TOWN OF NORTH ANDOVES 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 351 Willow Street key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. 2. System Owner: t� Bake 'N' Joy Name - ------- -- - -- reum 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): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed Z ndition of component pumped:�C�d Sludge Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. System Pump!V- /Z� ' 10-W---5 Truck# 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: St�ewart's Global Environmental, LLC, 20 So. Mill St., Bradford, MA 01835 Same /<�X � 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 u W City/Town of No. Andover - ° System Pumping Record JRN 0 5 2023 c, y( Form 4 iOWN OF NOril"H ANDOVER wM 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 351 Willow Street key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. 2. System Owner: t� _ Bake 'N'._Jgy_ Name - -- - ieM Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 4 1. Date of Pumping ( � - 2. Quantity Pumped: ---C - Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes to If yes, was it cleaned? ❑ Yes ❑ No 5. Observed ndition of component pumped: &3 m:7 Sludge Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. System Pumped Truck# - 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: Stew 's Global Environmental, LLC, 20 So. Mill St., Bradford, MA 01835 'Lti v� Same Signature of Hauler Date Same Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11112 System Pumping Record•Page 1 of 1 RECEIVED 12 Commonwealth of Massachusetts City/Town of No. Andover JAN 0 5 2023 o 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 351 Willow Street key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. 2. System Owner: Bake 'N' Joy Name ream Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 12_z_ _2.2 2 Quantity Pumped: Date 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 comp o t pumped: U Sludge Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. System P mp�d B Truck# Name Vehicle License Number J&S De lopment 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 RECEIVED Commonwealth of Massachusetts City/Town of No. Andover BAN p 5 2023 System Pumping Record TOWN OF6duFtVHANOOVEh ^M 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 351 Willow Street 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� Bake 'N' Joy Name rz� Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record f2 -2�-Z2 d 1. Date of Pumping 2. Q �� Date uantity 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 ndition of component pumped: C-dll9 - Sludge Observations are driver's opinion based on what he sees at time of um ing on the date above. 6. System Pumpe� : �' `- '\i ��" Truck# 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 is Global Enviror(mental, LLC, 20 So. Mill St., Bradford, MA 01835 �A(/ mil �J � -- 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 AECEIVELI _ Commonwealth of Massachusetts W City/Town of No. Andover a System Pumping Record TOWN Or NORTH ANDOVEIrt 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 _ 351 Willow Street key to move your Address cursor-do not No. Andover MA 01845 use the return Cityrrown State Zip Code key. 01_ 11 2. System Owner: V2L�l Name ---- -- ----- -- ----- — rerun Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 3 172 2. Quantity Pumped: ZS fl Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): - --- 4. Effluent Tee Filter present? ❑ Yes 2 No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 900 2- Sludge Observations are driver's opinion based on what he sees at time of pumping on the date above._ 6. System Pumped By: ^aSa-0 Truck# 33 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 _ �C.-ay, O ti es 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 RECEDED W City/Town of No. Andover jAN 0 5 NZ3 ° System Pumping Record TOW0OF NORTH ANDOVER Form 4 h � T;�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 351 Willow Street key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. 2. System Owner: t� Bake 'N' Joy Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping I 20— Z2 2 Quantity Pumped: Date 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: Sludge__ Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. System Pumped By: /J N t � , �. Truck# 133 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 RECEIVED Commonwealth of Massachusetts W� City/Town of No. Andover JAN 0 5 2023 System Pumping Record TOWN OF NOR"I'H 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 351 Willow Street key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. 2. System Owner: Bake 'N' Joy Name renrn Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): --- -- — 4. Effluent Tee Filter present? ❑ Yes (54--No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed co dition of component pumped: (�Ot� Sludqe Observations are driver's opinion based on what he sees at time of pumping on the date above. & Syst Pumped By: �f dry cis _ Truck# 3 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: Stewarf;s Global Environmental, LLC, 20 So. Mill St., Bradford, MA 01835 u �l j�� Same �c0� Signature of Hauler Date _ Same Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11112 System Pumping Record•Page 1 of 1 RECEIVED _ Commonwealth of Massachusetts W City/Town of No. Andover JAN 0 5 2023 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 key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. 2. System Owner: t� / -.fiQ Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record '�F�cx) 1. Date of Pumping Date 2 Quantity Pumped: Gallons 3. Compon ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): c5)y — `/ 4�I-e—'- 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed c dition of component pumped: add Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. System Pumped _ f 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' lobal Envir nmental, , 20 So. Mill St., Bradford, MA 01835 (Xl� Same (o ,� v Signature bf Hauler Date Same Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11112 System Pumping Record•Page 1 of 1 DECEIVED Commonwealth of Massachusetts W City/Town of No. Andover BAN 0 2023 System Pumping Record TOWN OF NODTH ANDOVEF+ 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 351 Willow Street key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. 2. System Owner: ub Bake 'N' Joy_ Name gun 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): - 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: Sludge Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. System Pumped By: n 0 PAt W _ Truck# ) 7 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•11112 System Pumping Record•Page 1 of 1 RECEIVED Commonwealth of Massachusetts W City/Town of No. Andover 3AN 0 5 2023 - System Pumping Record TOWN OF NORTH ANDOVER ,G^M Form 4 HE,;LTH 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. 2. System Owner: tb Name -- -- — ---- reAm Address(if different from location) Cityrrown State Zip Code Telephone Number B. Pumping Record � rO0O �F3,o�o 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspools ❑ 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: -90Q rA _Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. System Pumped By: ,;"44Q_�o Y� 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 Gllob_al Environmental, LLC, 20 So. Mill St., Bradford, MA 01835 V) TD 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 f Commonwealth of Massachusetts Y N��N p FR MEN E�* a1 City/Town of N6 ojAl'" System Pumping Record `�\AeA--1 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 ' w 6 ) key to move your Address cursor-do not MA use the return City/Town State Zip Code key. 2. System Owner: r� Name ---- - -- m4en Address(if different from location) City/Town State Zip Code Telephone Dumber B. Pumping Record 1. Date of Pumping (2 — - 2. Quantity Pumped: Date Gaf ons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap [Other(describe): S1 a ac, --- 4. Effluent Tee Filter present? ❑ Yes 4'No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: S 00� Observations are driver's opinion based on what he sees at time of pumping on the date above. 6. System Pumped By: /11 a so - 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•11112 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts AEGENED W City/Town of No. Andover W° System Pumping Record BAN 0 5 2023 Form 4 M _5 TOWN OF NOR NT ANDO EpARTME DEP has provided this form for use by local Boards of Health. Other MlOiiST Sy 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, ( y 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. t� 2. System Owner: Name - - --- -- --- Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record /I-- Z-ZL 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap 42/Other(describe): Sf �� '►1N 4. Effluent Tee Filter present? ❑ Yes [/No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: a--0 j Observations are driver's opinion baseq ofi what he sees at time of pumping on the date above. 6. S sty em Pumped By: "CLk 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 e ul Date Same Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11112 System Pumping Record•Page 1 of 1 ��vE�vEv Commonwealth of Massachusetts o Slo City/Town of No. Andover JPN rwO\JO' � System Pumping Record OF vePP Form 4 �o�N\ASN\- N 41y 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. 2. System Owner: reb .-r— a� N J Name amm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date -2-2- 2. Quantity Pumped: Gallons DOy 3. Component: ❑ Cesspo I(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap ZOther(describe): 4. Effluent Tee Filter present? ❑ Yes &v No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: I oU Observations are driver's opinion based on what he sees at time of pumping on the date above 6. System Pumped By: ^Ctl0-n 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 /4*/tGl SrM -_-TpTs Same Signature of Hauler Date Same Signature of Receiving Facility(or attach facility receipt) Date System Pumping Record•Page 1 of 1 t5form4.doc•11/12