HomeMy WebLinkAboutJanuary 2025 - Septic Pumping Slip - 351 WILLOW STREET 1/3/2025 Commo r � ealtf o Massachusetts
TOwn of Nod
Andover
City/TownNo.of
'  DEB 3 2025
System Pumping Record
Form{ Health
DEP has provided this fora for use by local Beards of Health, Other forms may be Fseadr,"u
information rust be substantially the same as that provided Isere. Before using this form, cheek 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 ether approving authority within 14 days from the pumping date in
accordance with 310 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1 4 System Location.
on the computer, � r
use only the tab
key to move your Address
cursor-do not l o. Andover MA `i 45
e e return �,.�. �,.�.. ..
ity town State Zip Code
. System Owner:
?Dake IV f f!
Name
rr SAME
Address(if different from location)
City/Town State Zip Code
Telephone Number
W
B. Pumping Record
1-3 1//.ow)
1. Date f Pumping .
Date-, g
Quantity Pumped: Gallons
1
Component: Cesspools El Septic Tank Tight Tank El Grease Trap
d,
F1 Other(describe):
. Effluent Tee Filter present? El Yes El No If yes, was it cleaned* [:1 Yes E:1 No
5. Observed condition of component pumped:
6,5�0 A All of this estimated
information is non-binding, valid on y et the tame ofof u in . i t responsible beyond the date above.
. System Pu ped By:
Name Vehicle Une Number. ....,.M....J..., ..�.�..�....,�.
J B C ev I pr ent Corp. d/b/a Stewart's Septic
Service
. Location where contents were disposed:
Stewe 's Receiving Facility 2 0 So. M III St-. Bradford, MA 0 1835
See above
Signature of Hauler Date
See above
lgneture of Receiving l=aollity(or attach facility receipt) � Date
i
t form4,doo•11/12 System Pumping Re ord Page I of I
i
i
Town
assach se � fqOdhConmonwealh MAn dove
}
City/Town of No. Andover
FEB
System Pumping Record3
f Form 4
local B 'ards of Health. Other forms 1 4.
r �P has provided this fora � � S�
' hey re using this form heo our
information rt� t b substantially the sage that provided of � -
local Board of Health to determine the fora 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 rove your Address _.....
cursor t No. Andover MA 01 �m.
use the returnCityfTown State,... Zip Code
key,
f... . System Owner:
T�j eon.
Name
Man SAME
Address if different from location
City/Town State Zip Code
Telephone number
B. Pumping Record
1. Date of Pumping
} �. Quantity Pumped: T �. ....._
Date Gallons
3
Cornet: Cesspool(s) Septic Tank Tight Tangy grease Tray
C.
Other(describe). 111.rr J
. Effluent Tee Filter present? El Yes 0 o If fires, was it cleaned? ❑ Yes E] No
. observed condition of Component pied:
.... All of this estimated
information is non-bi eyond the date above.
, System Pumped By: r...
dame vehicle License inner
J S Development Corp, d/b/a Stewart's Septic
Service
. Location where contents were disposed:
Stewa `. Receiving Facility, 20 So. II,IIill St., Bradford, MA 01 TM�...
n
Z/
.. �. See above
Signature of Hauler bate
See above
Signature of Deceiving Facility(or attach facility receipt) Date
Porn�4.doo• 1 System Pumping Record*Page I of 1
i
I
commonwealth of Massachusetts
City/Town of No Andover
System Pumping Record
h
Fora
DP has provided this fora 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#his fora, check with your
local Beard of Health to determine the form they use. The System Pumping Record or must be submitted to t
t
the local Beard of Health or other approving authority within 14 days from the pumping date i {
accordance with 310 CMR 16.361,
A., Facility Information
Important:When �
fillIng out forms 1. System Location:
on the computer, r
use only the tab
key to move your Address
cursor-do not
use the returnCity/Town State
icy.
2. System Owner:
Name
low
Address if different from location
};
No Andover MA $
11yrrown State Zip Cede
Telephone number
B. Pumping Record
100
1. Date of Pumping ��t � uantity Pumped. Gallons
34 Cow n nt;. ❑ Cesspool(s) Septic Tangy ....-.-.. E] Tight Tank roe Trap
D/OCher(describe).
. Effluent Tee Filter present? Yes No If yes,was it cleaned? Yes ❑ o
,erve 1 condition of component pumped;
. System Pumped By: .
'Ndmid Vehicle License Number
Stewart's SeDtic 58 So Kimball St. , Bradford MA
Company
. Location where contents were di posed-
20 So.-Mill t.,Bra for ,#1
-Slgnat re of I aul r D to
Signature of Recelving Facility(or attach faculty receipt) � gate i
t for .doa•11/12 System Pumping Record ord•Page I of 1
I
'i
Commonwealth of Massachusetts
} City/Town of No. Andover
.1
RN
System Pumping Record
Form
D P 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 i
accordance with 310 CIVIR 15.351 P
A. Facility Information
Important:when
filling out forms I. System Location:
on the computer,
use only the tab 351 Willow Street
ley to more your Address ...�N
cursor not No. Andover MA o 84
return use the rt�� ityfTo�rt� State ..�..... �...� �
key, ��
2. System Owner.
Bake'N' Joy. .�
Name rM.
rrr SA M
Address different from location) IL
City/Town State Zip Code
Telephone NOmber. _.
B. Pumping Record
1. Date of Pumping l
.�. �.. .. . Quantity Pumped:
�Dat Gallons
. Component: El Cesspool(s) Ej Septic Tank Ej Tight Tank 0 Grease Trap
El""6ther(describe):
. Effluent Tee Filter present? Ej Yes [0-:u o If yes, was it leave ' ❑ Yes ❑ No
. observed condition of component pumped:
Cr
All of this estimated
information is non-binding, valid one t the time of u in blot res nsible y nd the date above.
e.
M.... . p
6.
System Pumped By:
� .. �... �...... ,w,
Name a Vehicle License Number
r
J S Development Corp. 1 Stew rt's Septic
Service
7. Location where contents were disposed,
Stews .s Receiv1n F aci I ity 20 So,r.._l liII St.F Bradford, MA 0 133
.. ..;; See above
Signature of Hauler Date
See move
Signature of Receiving Facility or attach facility receipt) Date
t form .d c•11/12 System Pumping Record*Page I of
{
Commonwealth
of Massachusetts
r
City/Town of.No. Andover
+ System Pumping Record
Form
D P has provided this form for use by local Boards of Health. other forms may be used, but the
information rust 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 t
the local Board of Health or other approving authority within 14 days from the pumping date}in
accordance with 310 C MR 15 35 1.
A. Facility Information
Important:When
tilling out forms 1. System Location:
on the computer,
use only the tab .. 1 Willow Street
key to move your Address
cursor do net No, Andover MA o
use the return
ity Town Staten of
key.
. System rn r-
z
-� .
qy FEB
Name
RAM
SAME
0%V%
Address if different from location) �.w. ��� i 8 �
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping gate - Quantity Pumped: lion
3. Component: El Cesspools ❑ Septic Tank Ej Tight Tank El Grease Trap
Other(describe):
. Effluent Tee Filter resent'? El Yes �� o if es was it cleaned' ElYes l`pf
5. Observed conotion of component pumped:
All of this estimated
information is non-binding, valid only. t the time of uTr pi g...N t r sp n l 1 _��nd the date above.
. Syte Pumped By:
J
Name vehicle License[dumber
AS Deveiopment Corp. dlb a Ste art's Septic
Service
. Location whore contents were disposed:
Stews .t�.. ceivin Facility, 20 So. bill St,, Bradford, M 01835
f ,, x above
fee
ig nature of Hauler Date
See above
Signature of Receiving Facility or attach facility receipt) Date
t form .doc• 11112 System Pumping Record•Page I of 1
i
Commonwealth of Massachusetts
Town ofNofth Andover
City/Town of No. Andover
R FEB 3 2025
System Pumping Record
w
.*# Form
He I
local hoards of Health. orms ���
P h provided the form for u Other
F
information must be substantially the saute as that provided here. Before using this for check with your
local Board of Health to determine the form they use. The System Pumping Record rust 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 In
Important:When
filling out forms 1. System Location:
on the computes`, ,�
_ V0
use only thetab
.. .....-
key to move your Address
cursor-do not No. Andover MIA o1
use the return �...�.. _... �,. µ .....
ey, City/Town State Zip Code
2. System Owner:
(e
Nacre
e SAME
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping DI t FY .- � Quantity Pumped: _2z/I 1J61)
Gallons
...�.......,�.. _
. Component: El Cessp of s E:1 Septic Tank E:1 Tight Tank El Grease Trap
ET'Other(describe): -....{ 4.
4. Effluent Tee Filter present? F1 Yes ._- o If yes, was it cleaned? Yes No
. Observed co
dition of component pumped:
All of this estimated
f,
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.--
System Pumped Bye..
f _J
Name Vehicle License Number
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, III `f
835
r -
r` ..f, ' h[ See above
--
ln �ture of Hauler' Dante
See above
Signature of Receiving Facility or attach facility receipt) Gate
t form4.d c• 11/1 ystem P rnping record•Page 1 of 1
i
Commonwealth of Massachusetts
4
Ci�� � of I`�o. hover
ToTowOrth
M1
t
System PumpingRecord
,� Form
FE9
32025
P has provided this fora for use by local Boards of death. Oth rrr y be used, but the
information must a substantially the sane a that provided here. t check with your
local Board of Health to determine the fora they use. The System Pumping i e o9 Wmitted 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
Ming out forms I System Location;
on the computer,
use only the tab �..�. 5 Willow Street
key to more your Address -cursor de not o. Andover MA 01845
use the return itrlTow+r� ....�,�. .state � bode
key. p
2. System Owner:
ae 'I ' Joy
Name
err SAME
......
Address if different from locations Y. �,,,M„ ,
ityfTown .. Mate Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping . Quantity Pumped: ...................
�� . .
Date Gallons
34 Component:ent: ❑ Cesspools ❑ Septic Tank Tight Tank ❑ Grease Trap
......y......
r�a�;�fi=
❑ Y l■M r (describe):
4. Effluent Tee Fitter present? ❑ Yes 0-No If yes, was it cleaned? ❑ Yes N o
5. Observed con ition of component pumped:
..
_.nf All of this estimated
information i non-binding, valid oniy at the time of pu �p0g. Not resp �siioie beyond the date above.
. System Pumped Qy-
Name Vehicle License Number
AS Development Corp, d la tewart"s Septic
Service
. Location where contents were disposed
StewpA s RecejiFacllty, �o, Dili fit,, rafor �5 r.. .4
See above
Signature of Hauler Date
_ See above
Signature of Receiving Facility or attach facility receipt) Date
.
f f rm4.doc# 11/12 System Pumping record•Page I of I
i
Commonwealth
City/Towno No. Andover
System Pqmping Record
w
.. Farm {4
EP has provided this form for use by local Boards of health. Other forms may be used, but the
information must be substantially the sane as that provided here. Before using this fora, check with your
local Board of Health to determine the fora they use. The System Pumping pin Record must be submitted to
the local Board of health or other approving authority within days from the pumping date in
accordance with 310 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab ......, 351 Willow Street . TOwn Of
key to move your Address --do
er
cursor-do not , Andover � � MA 01
use the return DIt�rlTov�r� ..�».... Mate i de
key. FED
2. System Owner:
Bale' ' Joy i, . .
Name
Meat
team
SAME
Address(if different from location) ,....w.N. .w.w w. ., w.
City/Town StateZip Doke
Telephone Number
B. Pumping Record
(7
. lute of PumpingDate 2. Quantity Pumped: Gallons�. ............
3. Component: ❑ Cesspool(s) El Septic Tank El Tight Tank ❑ Grease Trap
tether(describe):
(7 m....n ��... .
4.
Effluent Tee Filter present? El Yes fro If yes, was it cleaned? ❑ Yes El No
. Observed condition of component pumped:
dw '4-- All of this estimated
information is non-bindin valid onl t the tune of umr)ingi Not responsible beyond the date above.
. System Pum ed By:
Name Vehicle License number
AS Development Corp. d b/a Stewart's Septic
Service
. Location where contents were disposed:
ate tiffs Receiving Facility,20 So. Mill St., Bradford, MA 01835
57
See above
S1 nature o Date
See above
Signature of Receiving Facility(or attach facility receipt) � Date
t form4.boo#11/12 System Pumping Record•Page 1 of 1
k
Commonwealth
City/Town of No. Andover
System Pumping Record
.* Form
DEP has provided this form for use by local Boards of Health, Other forms may be used, but the
information rust be substantially the sane 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
trey to rove your Address
cursor do not No. Andover PEA o135
use the return f `itywn Mate �. ToWn 6t CPde
.
IvOrth
2. System Ownertab
- dover
Bake'N' Jo
Name
06
IMM
SAME
Address if different from locations . ..... P eN
City/Town state w� Zip Cede-
Telephone Number
B. Pumping Record
5M
1, Date of Pumping Date . . Quantity Pumped, aii
3, Component: El Cesspools Septic Tank El Tight Tank El Grease Trap
4
Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned' ❑ Yes El No
5. Observed condition of component pumped:
All of this estimated
information is non-bi .dip. , valid only at the time of pumping.., Not res onsile beyond the date above.
. Sy t Pump d B •
Nahne Vehicle License i umb r
J S Development ent Corp. d/b a Stewart Septic
Service
'. Location where contents were disposed:
Stewar ' ving E il __ rd, A 5
See above
Date .. �-
See above
Signature of Receiving Facility or attach facility receipt) Date
t5fomi4,docs 11/12 System Pumping record*Page I of 1
Commonwealth of Massachusetts
t w
City/Town of No. Andover
. r
i
System Pumping Record
Form
.,g ,
P has provided this form for use by local Boards of Health. Otter forms may be used, but the
information must be substantially the sane as that provided here. Before using this form, check with your
local Board of Health to determine the fora they use. The System Pumping Record rust be submitted to
the local Board of Health or other approving authority within 14 days from the pumping ping date i }
accordance with 310 CMR 15.351,
A. Facility Information
i
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. And over 11 A `I
use the return .___,..... -
key. ItylTown State Zip Code
+x
2. System Owner.
Bake l Joim Town of No Andove-.....�.� .
Name
r r SAME
�. .........N_...
Address if different from location) ..........
2025
. ......... �..
itylTown Mate Zip Code
Hea
Telephone Ibex - ,.k......
B, Pumping Record
1. Date of Pumping Date antity Pumped. Gallons
w.w
3. Component, FCesspool Septic Tank ❑ Tight Tank Ej Grease Trap
Other eerie : � T.. ..
. Effluent Tee Filter present? Yes No if yes, was it cleaned` El Yes El No
5. Observed condition of component pumped:
All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
. System Pumped B-P
x F
Name Vehicle License Number
J&S Development Corp. dlble Stewart"s Septic
Service
. Location where contents were disposed,
Sfewa %Receivinq Fa ilityF 20 Bo. Mill St., Bradford, MA 01835
t � :.... Bee above :
slgna ore of Hauler Date
See above
Signature of Receiving Facility or attach facility receipt) Date
t form4.doci 11/12 System Pumping record#Page I of I
i
Commonwealth of M
City/Town of N . Andover
System Pumping Record
Form 4
4
i
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 fora they use. The System Pumping Record gust be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 QMR 15.351.
A. Facility Information
Important:When
n
filling opt forms 1. System Location:
n the computer,
use only the tab
351 Willow Street
key to move your Address
cursor o not No. Andover MA o
use the return �...�.. �.�.
key. City/Town State —... own
i
Andover
f
. System owner:
r
�_._. .. . .�.......ry-.m..n...x._ B a ke'N' J oy EEA
NameKP
rra SAME _
Address if different from location) Health epartM
.
DIt ffown State Zip Code
Telephone Number
C . Pumping Record
4e
1. Date of Pumping 2, uan :. � .. T, .................
Date Pped, Gallons
3. Component: Ej cesspools ❑ peptic Tank
Tight Tank El Grease Trap
v
Other(describe):
4. Effluent Tee Filter present? El Yes El No If yes, was it cleaned' El Yes El No
. Observed condition of component pumped:
All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. System Purnpd. t
Marne Vehicle License Number
AS Development Corp, d/b a Stewart's Septic
Service
. Location where contents were disposed;
Stewa rts 4 eceiv1 ng I acii ity 20 So. Mill St,, Bradford MA o
2 .........
_ See above
�+Signature HauleroHauler ��...:.�...�.,,. Date .. m,
_ Bee above
I nature of Receiving ing Facility or attach facility receipt) Date �w
t form .doo* 11112 System Pumping Record*Pave i of I
Commonwealth
R City/Town
a
System Pumping Recor
t
Form
'.I
L BP 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 fora 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 tad
351 Willow Street
key to move your Address
cursor-do not No. Andover MIA 01
use the return City/Town state dIe . Town ofAndover
2. System owner:
B e ' "w oy -..,FEU
Name
fella SAME
Address If different from location)
Health D epartmQat
ItylTown State Zip Code
Telephone hirer
B. Pumping Record
.r. �
1. Date of Pumpingt 2. Quantity Pumped: Gallons
3. Component: El Cesspool(s) El Septic Tank El Tight Tank ❑ Grease Trap
ST
�. r
other (describe): f ......�
s 5
Effluent Tee Filter present? El Yes [j/N0 If yes, was it cleaned? El Yes El No
. observed condition of component pumped,
..... xm All of this estimated
information is non-bind! alid only at the"'t'ime of pumping. Not responsible beyond the date above.
B. System Pumped B :
Name Vehicle License Number
J S Development Corp, dlbla Stewart's Septic
Service
7. Location where contents were disposed-
Stewaffs RecelviN Facility, 20 o."Miil St,, Bradford, MIA 01835
y ' ... See above
� In ��lrefaul ,, -
�, Date
See above
Signature of Receiving ivin Facility or attach facility receipt) Date
t5 fo rm4.doe# 11112 system Pumping Record•Rage I of 1
Commonwealth
{ City/Town of No. Andover
+ fSystem Pumping R
Y Form
Al.
D P has provided this form for use by local Boards rds of Health. Other forms may be used, but the
information rust 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 focal Board of Health or other approving authority within 14 days from the pumping ping date in
accordance with 310 CMR 15.351,
A. Facility Information
Important:When
filling out forms 1, System Location:
on the computer,
us only the tad ....... .' . .�.
351 Willow Street
...key to move your Address `
cursor do got N . Andover A 01845
use the return City/Town ..�......
key. state i
151...............
Tow6by%fod Andover
............
. System Owner.
Bake ' ' .boy.v.��..._
Name I LU
(eon SAME
E
..�.....»....�.......
Address if different from location)
Health Departm
ityfro rn State Zip Code µ
Telephone Number
B. Pumping Record
0
��. 5
1. Date of Pumping Dade 2. Quantity Pumped,.
ao
3. Component: El Cesspools ❑ Septic Tank Ej Tight Tank El Grease Trap
2/000ther describe
4. Effluent Tee Filter present' El Yes El No If yes, was it leaned` Ej Yes El No
. Observed condition of component p mpe :
4 �cc)
All of this estimated
information is non-binding, valid at the t e of um in . Not res oribie rd tle date above.
. System Pum ed By,
III r#
-------------------------
Name Vehicle License N-6 ber :.
AS Development Corp. d b a Stewart Septic
Service
. Location where contents were disposed:
Stewart's Receivin Faoi' 20 So. frill St., Bradford MA 01835
See above
of Hauler Date �,......� . .... :.
_ See above
Signature of Receiving Facility or attach facility receipt) Date
t form ,do • 11/12 System Pumping Record i Page I of I
Commonwealth of Massachusetts
City/Town of No. Andover
.. Y
System Pumping
h Evan
DES' has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the sane as that provided here. Before using this form, check with your
local Board of Health to determine the fora 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 CM R 15.3 1.
A. Facility Information
Important:When
filling out forms 1, System Location:
on the computer,
use only the tab . 351 Willow Street
trey to move your Address mm .
cursor-dot o. Andover MA o1
use the return City/Town � ...... tat � I Code
key. OwnofNo
nh AndOver
2. System Owner,
Bake ' ' o ....
Name25
�....�-
[eon SAME
Address if difFefent from location
1t 4r-
00,p—art
City/Town State Zip co!Pda��IL
Telephone Number
B. Pumping Record
1. [date of Vamping gate . Quantity Pumped: gallons
3. Component; El Cesspool(s) El Septic Tank El Tight Tank El Grease Trap
OzOther(describe):
. Effluent Tee Filter present* ❑ Yes _�. No If yes, was it cleaned' ❑ Yes ❑ No
. Observed condition of component pumped;
.. All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
System Pumped
Name Vehicle License Number
S Development Corp. d/bla Stewart's Septic
service
7. Location where contents were disposed;
Sf wa rtp Recetvi ng. Fa ilit ,2 -So. M i I I St., Bradford} MA 0 18 3 5
. ...� -- See move .. 4
i at�ro of Hauler � date � .... n..
See move
Signature of Receiving Facility or attach facility receipt) Date
t forrr .d oce 11 12 System Pumping Record•Wage I of I
Commonwealth of Massachusetts
i City/Townof No. Andover
M F I
Le
! I
.Y
r System Pumping Record
x
Form
v
D P 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 fora 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-ale not I
Nor Andover II o1
use the return
Ivey. itylTown ... .. state .. i de .._._.._.-._.__
. System Owner:
TOwn of Nod
A
Bake �o
Name
SAMEv.m. FE 3.......
Address if M.w
different ffom location)
r ... ...... _-. .._-.-........
City/Town state � D l Code
aIT
Me
Telephone Number B. Pumping Record
•fiJ � 30b
1. Date of Pumpi ng Date , Quantity Pumped: Gallons
3. Component: ❑ Cesspools El Septic Tank El Tight Tank El Grease Trap
VO/Ither(describe). .. n..
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of co ponent pumped:
� cx�
f this estimated
information is non-binding, vVid one zYthe time f �rn� in . dot res on ibl be and the date above,
. System P nped By:
Name ^TM Vehicle License Number �
S Development Corp. d/b/a Stewart"s Septic
Service
7. Location where contents were disposed:
Sfewart's F eoeivi ng FaeiIit , 2 0 So. I IiII St., Bradford, MA 0 1
See above
. at of Hauler ... .. ... [ t
See move
Signature of Receiving eivin Facility or attach facility receipt) Cat —�
form .doc• I 1112 System Pumping Record•Page 1 of 1
1
Commonwealth
:f City/Town of Not Andover
M1
System
w
Form
4
EP has provided this fora 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 fora they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority vithin 1 9da s from the pumping date in
accordance with 310 CMR 15.351.
A. Facilityinformation
Important:When
filling out forms 1. System Location:
n the computer,
use only the tab . 361 Willow Street
key to move your Address
cursor do not No. Andover MA 01845
use the return .
trey. City/Town state Zip code
2. System Owner,
.
Town ()
fA
Bake 'N' Joy rth A doVV
Name
rtrr SAME FER
Afte if different from location)
lity/Town Mate Zip Code
PaftM
-e n
Ve
Telephone Dumber
B. Pumping Record
-3
, Date of Pumping gate � Quantity Pumped: GallonsT-.
34 Corpoert; ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank El Grease Trap
abther(describe): f _
. Effluent Tee Filter present? Q Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
. Observed codition of component pumped;
224� .............. All of this estimated
information n is non-bi di rig,.valid only at the time,of pumping. Nt responsible beyond the date above.
. System Pumpedfp
A� 5
Name vehicle License Number
er
AS Development Corp. d la Stewart s Septic
Service
. Location where contents were disposed:
Stevan F e eivi n g Facility,20 So. MiIt St. Bradford, MA 0 18 3 5
See above
Signature of Hauler Date .
See above
Signature of Receiving Facility or attach facility receipt) Date
t forr .doe#11112 System Pumping Record Page I of I
Commonwealth
City/Town of No. Andover
System Pumping Record
Form
D P has provided this form for use by local Boards of Health. Other forms may be used, but the
information rust 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 abate in
accordance with 310 GAR 15.361.
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 o not No. Andover MA 01845
return
the ret�� City/Town ... .. � State ... - i bode ,.
ley. p
2. System Omer:
rah Town
Bale VL4qy
Marne
SAME
Address f different from location)
025
lty 'on StateZip Code' A
Dep rth'%..
Telephone umber e�i
B. Pumping Record
3 � �
1, Date of Pumping at 2, Quantity r Pumped: ,...w
Gallons
3. Component: El Cesspools ❑ Septic Tank Tight Tank ❑ Grease Trap
}
❑ Other(describes .
4. Effluent Tee Filter present's Ej Yes E No If yes, was it cleaned? ❑ Yes No
Observed condition of component pumped:
All of this estimated
information is non�bin ire , valid or�1 �the i of p nn ing. �o r s o sibie beyond the date above.
. System Pumped By:
Name Vehicleµ License Number
J S Devel present Corp..d/b/a St rart's Septic
Service
. Location where contents were disposed:
ate arts eceiv ..Facility, 20 So. Will St., Bradford, MA 01836
See above
Signature of Mauler Date
See above
Signature of Receiving eiving Facility or attach facility receipt) Date
t forn .doc System Pumping Record Page I of 1