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Home My WebLink AboutGrease Trap, - Septic Pumping Slip - 351 WILLOW STREET 8/8/2024 Commonwealth of Massachusetts City/Town of No. Andover AUG 0 8 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 No. Andover MA 01845 use the return _...--- -- - - -- ---- — — --- ---- -___----- ------ key. City/Town State Zip Code 2. System Owner: Bake'N' J_oy Name SAME Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping _30 DDate2. 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 co ition of component pumped: G-00 SLUDGE All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the 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 's Receiving Facility, 20 So. Mill St.,-Bradford,-MA 01835 �"/C See above ` � 69 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 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. System Location: on the computer, 3 \� use only the tab _ J L✓/ ��✓ 351Willow Street _ key to move your Address cursor-do not No. Andover_ MA 01845 use the return key. City/Town State Zip Code 2. System Owner: VIkA �e 77' -- Bake'N'JOy-- ----- Name SAME Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Z� _' 2. Quantity Pumped: D� 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 All of this estimated information is non-binding, valid only at the time of pumping. Not responsiblebeyond the 6. Systergumped B Nam Vehicle License Number J& velopment Corp. d/b/a Stewart's Septic Se ice 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 "JCS Commonwealth of Massachusetts City/Town of No. Andover AUG 0 8 2024 System Pumping Record Form 4fi H S 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 ---- --- -- -- - -- - - --- - - --- key. City/Town State Zip Code 2. System Owner: Bake'N' Joy NameSAME 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 All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the 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 t5form4.doc•11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts = City/Town of No. Andover System Pumping Record AUG 4 8 L'L`, 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 No. Andover MA 01845 use the return ----- - - - --. ._ - - - -------- - - ------ key. City/Town State Zip Code 2. System Owner: V� Bake'N' Jo_______ Name � SAME Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record Q� Q 1. Date of Pumping Date Z3 ZY 2. Quantity Pumped: gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): - -- -- - 4. Effluent Tee Filter present? ❑ Yes [�J/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 6. System PP ped B Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Stewart's Rece ving Facilit 20 So. Mill St., Bradford, MA 01835 See above 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 City/Town of No. Andover - System Pumping 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. 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 ---- --- ----_ ------------------ key. City/Town State Zip Code 2. System Owner: V� Bake'N' 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: CO Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): ---- 4. Effluent Tee Filter present? ❑ Yes<O-Pto If yes, was it cleaned? ❑ Yes ❑ No 5. Observed con tion of component pumped: d0 SLUDGE All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the 6. System Pumped B Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Ste a Receiving Facility, 20 o. Mill St., Bradford, MA 01835 fc ,� e-- > See above �f 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 a1 City/Town of No. Andover System Pumping 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. 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 ------._---- _ - - — _-- --- ----- - -- --— - - - key. City/Town State Zip Code �1 2. System Owner: Bake'N Joy Name SAME - ------- -- Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record q000 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 All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the 6. System Pysnped Byi J1612 Name IVehicle 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. Will St., Bradford, MA 01835 See above ure 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 Andover City/Town of No. Andover 4UG 0 g 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 No. 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 -' —L -- 2. Quantity Pumped: -- Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes EZ_No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: C_s--c 6) SLUDGE All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the 6. System Pumped`_ Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Stewart's7Receiving Facility, 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 _ Commonwealth of Massachusetts '► Andover. City/Town of No. Andover System Pumping Record AUG 0 S 2024 r` 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 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 I 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): - --- Sludge 4. Effluent Tee Filter present? ❑ Yes 2-jNo 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. System Pumped By, Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: 7=,lFaTQ_So. Mill St., Bradford, MA 01835CV7 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 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. 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 Joy - Name - - - - --- � SAME Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 7 -t t '3 ) 00 - 1. Date of Pumping Date - 2. Quantity Pumped: Ga ons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): — - - _—__— _. _ Sludge 4. Effluent Tee Filter present? ❑ Yes R(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. System Pu ped 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 S' a e Hauler Date SAME Signature of Receiving Facilit y(or attach facility receipt) Date t5form4.doc•11112 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts T0 Ll I Andover City/Town of No. Andover System Pumping Record AUG 0 S 2024 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 — 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 q -T - OU 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? ❑ Yeses No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed co dition of component pumped: d, 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 B�I Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Stews 's Receiving F cilit , 20 So. Mill St., Bradford, MA 01835 C �. �1 �L 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 _ Commonwealth of Massachusetts TV�en' L lall ��GI City/Town of No. Andover AUG o 8 2024 System Pumping Record -- e Form 4 - h ri+'n0C1t 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 D J — 2. Quantity Pumped: Gallons O 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): -- - -- -_-- --Sludge 4. Effluent Tee Filter present? ❑ Yes T 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. System,�Pumped By: 1 Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Stewart's Receivin acilit , 20 So. Mill St., Bradford, MA 01835 _ See above n of Ha er Date SAME Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 �; o � Andover Commonwealth of Massachusetts City/Town of No. Andover 2024 System Pumping Record Form 4 gC1t �epa'�m DEP has provided this form for use by local Boards of Health. Other forms rpApiiAed, 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 I CCO 1. Date of Pumping 2. Quantity Pumped: � Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): - — ---- -- Slud�c e 4. Effluent Tee Filter present? ❑ Yes k No If yes, was it cleaned? ❑ Yes ❑ No 5. O/bss"erved c ndition of component pumped: lJ'-ay 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.- Name Vehicle icense Number J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Ste Receiving Facility, 20 So. Mill St., Bradford, MA 01835 r_k a4 See above Signature of Hauler Date SAME Signature of Receiving Facility(or attach facility receipt) Date t5form4.doca 11/12 System Pumping Record•Page 1 of 1