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Home My WebLink AboutGrease Trap, E.Q., Sludge Tank, - Septic Pumping Slip - 351 WILLOW STREET 9/9/2024 Commonwealth of Massachusetts 2p24 City/Town of No.Andover �- System Pumping Record Form 4 r � v 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 G cursor-do not use the return City/Town State Zip Code key. 2. System Owner: Name snm 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 0 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap [Other(describe): 1�' 4. Effluent Tee Filter present? ❑ Yes E�No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: tKCe_SSj-V,e S01,'6S &Qj- rM3 6. System Pumped By: gsc,ft 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 10('f-3 lQyI/ �'-f 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 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+��1 2. System Owner: V� -- -- - -- Bake'N'J ------ -- Name -------- —____ SAME Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping g Z 2 2. Quantity Pumped:y Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yesc& No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed7ndition of component pumped:C SLUDGE All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the 6. System Pumped B /n. °'^ ------ �� - --- -- - Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Stew 's Receiving Facility,20 So. Mill St., Bradford, MA 01835 See above U `� 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 z 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 No. Andover MA 01845 use the return --- --__- ---- ----------- ---- key. City/Town State Zip Code 2. System Owner: r� _ Bake'N' Jo�r 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: Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): - ------- - 4. Effluent Tee Filter present? ❑ Yes PNo 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 Facie, 20 So. Mill St., Bradford, MA 01835 _ See above Si u er Date SAME Signature of Receiving Facility(or attach facility receipt) Date t5fonn4.doc•11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of No. Andover System Pumping Record 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 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 7 1. Date of Pumping 2. Quantity Pumped: Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap E Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: G-v o� SLUDGE All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the 6. Syst Pum ed By- NamK Vehicle License Number J&4,6evelopment Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Stewart's Receiving Facili�, 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 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 ------ ------- — - ---- ---------- -- ---- ------ City/Town key. City/Town State Zip Code 2. System Owner: V� Bake'N' Joy .--— Name ------------ -- _ -- SAME Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record �a 1. Date of Pumping Date Gallons 2. Quantity Pumped: 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes 0"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 B Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Stewart's Receivin Facility, 20 So._Mill St., Bradford, MA 01835 S See above Signdfure 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 r` 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' Job-- -- -- — -- Name SAME Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record C�� 1. Date of Pumping Date✓t 'Z - 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): ----------- -------- 4. Effluent Tee Filter present? ❑ Ye�o If yes, was it cleaned? ❑ Yes [7'No 5. Observed condition of compo ent pumped: �7, 7 SLUDGE All of this estimated infQrrhation is non-binding, valid only at the time of pumping. Not responsible beyond the 6. System�t�d 2 X. L Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Stewa ' acility, 20 So. Mill St., Bradford, MA 01835 See above 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: - -- -- Bake Name � SAME Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date t6 Z 2. Quantity Pumped: Gale 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): - 4. Effluent Tee Filter present? ❑ Yes LR 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: t W A - 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 V See above nat a 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 G System Pumping Record Form 4 r�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: r� _ Bake'N' Jam__ 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: Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): / --— 4. Effluent Tee Filter present? ❑ Yes L"�d' 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 Pum�ed By.- Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Stewart's R �g Facility, 20 So. Mill St.,-Bradford, MA 01835 See above _ o r 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 r` 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: r� 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 �3 2. Quantity Pumped: Gallons 3(oOo 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes MeNo 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 �d By - - - - - Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Stewart's Rec wing Facilit , 20 So. Mill St., Bradford, MA 01835 _ See above 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 p 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 No. 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 1. Date of Pumping 2. Quantity Pumped: --- - Date Gallons 3. Component: ❑ Cesspool(s) /❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): S1 vK 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. Syste mped By' �4- Nam Vehicle License Number J& evelopment Corp. d/b/a Stewart's Septic S 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 Commonwealth of Massachusetts W 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 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 DatteN ? 2. Quantity Pumped: Gallons O 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: SLUDGE All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the 6. System Pu pe y: Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Stewart's Receivinq Facility, 20 So. Mill St., Bradford, MA 01835 See above_ �YHBIer ��_ 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 W 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 City/Town State Zip Code key. P 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 3 D �vI 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): _ Sludge 4. Effluent Tee Filter present? ❑ Yes,J)a*lNo If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: ��J Sludge All of this estimated information is non-bind' , valid only at the time of pumping. Not respo�ond the date above. 6. Syst,na-R 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 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 W 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 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 2. Quantity Pumped: Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ® Grease Trap ❑ Other(describe): -_ Sludge 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 0 <� Sludge All of this estimated information is non-binding, valid only at the time ofpum in . Not responsible beyond the date above. 6. System P ped B Name Vehicle License Number J&S D elopment 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 T t5form4.doc•11/12 System Pumping Record•Page 1 of 1