HomeMy WebLinkAboutFebruary 2025 - Septic Pumping Slip - 351 WILLOW STREET 3/4/2025 Commonwealth of Massachusetts
To
City/Town o No. Andover Iol
wI System Pumping Record
T Form 4 MAR ,
DEP has provided this fora for use by local Boards of Health. other fo s used, the
information must he substantially the sane s that provided here. Bed r f 1� Fro with your
local Board of Health to determinethe form they use, The System Pumping record 4 ' to to
the local Board of Health or other approving authority within 14 days from the pumping plate in
accordance with 310 GMR 15.35 .
A, FacilityInformation
Important,When
filling out forms . System Location:
on the computer,
use only the tab � 1 Willow Street m my
key to move your Address
cursor do notNo. Andover MA 01845
use the return .. �... ..,
key ityfTon _ State Zip code
r
2. System Owner;
oe Name
Bake F1' Joy
vm, r.. ,.�. .... �....
r r SAME
Address if different from location)
City/Town State Zip code
Telephone Number
B. Pumping record
1. Date of Pumping �, Quantity Pumped:
Date
. allows
3. Component'.nt'. ❑ Cesspool(s) Ej Septic Tank ❑ Tight Tank crease Tree
'+ S
mother WescribeY ....
4. Effluent Tee Filter present? Ej Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed eon ltion of component pumped:
All of this estimated
information is nonRirclin , valid onl t the#ire o urn i . dot res onsile beyond the Mate above.
. Systeg Pumped
5 Na Vehicle License Number
ev lopl ent Corp. dl Stew rt's Septic
Service
, Location where contents were disposed:
Stew rt's Recei in F qc1l ity,20 So. M i I I St., Bradford, CIA 01 3
See above
Signature of Hauler Date
See above
Signature of Receiving Facility or attach facility receipt) Date v
t form .doc• 11/12 System Pumping Record Page I of 1
1
Commonwealth of MassachusettsTown of Nod Andover
City/Town of No. Andover
� Y
n
System Pumping Record
Form
EP has provided this form for use by local Boards of Health. �4 r � the
information rust a substantially the same as that provided Mere.�e oreV14"INL.ckwith 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 CMR 15.361.
A. Facility Information
Important:When
filling out forms 1. System Location;
n the computer,
. use only the tab ,.
3 Willow low Street
fey to move your Address
cursor t No. Andover MA 01845
use the return m. .. ... .
key Cityf%wn Stag Zip Code
r
. System Owner:
Bale 'N' .goy
Name
SAME
Address if different from locations �..m................,
CltylTown State Zip Code
Telephone Number
B,, Pumping Record
1. Date of Pumping Date . Quantity P rped: Gallons
3. Component: E] Cesspools Septic Tank El Tight Tank 0 Grease Trap
M/"Other(describe): �.. ,
4. Effluent Tee Filter present? Yes . No If yes, was it Cleaned? El Yes ❑ No
. Observed c %ndition of Component pumped:
All of this estimated
information is non-binding, valid only at the time of...pumping. Not responsible bey9nd the date above.
{ . System Pumped By:
�r
Name � Vehicle License dumber
S Development Corp. d/b/a Stewart's Septic
Service
. Location where contents were disposed:
Stewart' Rec/eiving Facility 2 20 So. Mill Std Bradford, MA o 1835
1 ,.k '� See above ` `-
t/Sz1gn-atu—r'e of hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
t ferm4.de *11/12 System Pumping Record rd *Paige I of I
TOwn Of NOrth Andover
�L\ Commonwealth of Massachusetts
4fIrCity/Town of N . Andover
MAR
--4.
System Pumping Record .2025
Form
DFP has provided this form for use by local Boards of Health, Other forms may be s 900ent
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 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 Information
Important:when
filling out forms 1. System Location':
on the computer,
1 willow Street
use only the tab 3
,
key to rove your Address
cursor-do not No. Andover M 01845
use the return ..
key City/Town State i Code
2. System Owner:
to
Bate'N'Joy
Name
r i SAME
Address if different from location)
City/Town State Zip Cole
Telephone plumber
B. Pumping Record
2. Quantity Pumped:
�. Date Pumping Date umpe lions .v....
3. Component: El Cesspool(s) El Septic Taal E] Tight Tank [:1 Grease Trap
� vim:....._..
ti
other(describe). m -6i, m ......... ......w.... �
. Effluent Tee Filter present? El lies 9 o If Yes, was it cleaned' El Yes El No
. Observed condition of component pumped;
f r All of
this estimated
information is n - idrn valid onl at the tie c prrr�plg� dot responsible beyond the date above.
O. System Pumped By:
rName vehicle License Number
f
AS Development Corp. d/b/a Stew rt's Septic
Service
. Location where contents were disposed.
Stewart'§ Receiving Facilltv, 20 So. bill St,, Bradford, MA 01835
.� See above .{ �
'—Signature of Hauler Date �..._..._
7 See above
} Signature of Receiving Facility r attach facility receipt) bate
f form .do System Pumping Record•Page I of t
Commonwealth of Massachusetts
Town
:} City/Town of No. Andover hndover
System Pumping Record
MForm
I EP has provided this form for use by local Boards of health, OtNvj y b used, but the
+ r * r +
information must be substantially the same s that provided here, e o f , check with your
local Board of Health to determine the fora they use. The System P mpinc l ec r brnitted to
the local Board of Health or other approving authority within 14 days from the pumping date i
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
1 Willow Street
� of the tab _.
key to move your Address
cursor R do not No. Andover MA 1
use the return
w�. _-.
key City/Town State Zip Code
2. System Owner:
Bake 'I 'Joy
Name
SAME
Address(if different from location)
ityfro n _.. ... ... State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:Date
Gallons
, Component; E:1 Cesspools Septic Tank Tight Tank El Grease Trap
E11e6ther(describe):
. Effluent Tee Filter present? El Yes -No If yes, was it cleared? 0 Yes E] No
5. Observed condition of component pumped:
Y ... All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
. System Pumped y;
k
Marne Vehicle License Number
J S Development Corp. d b a Stewart s Septic
Service
'. Location where contents were disposed:
Stewar's Rece ivi n g FaciI it , 2 0 So. M 111 St., B rad ord r MA 0 18 3
See above `'.X
Signature of Mauler Date
_ See above
Signature of Receiving Facility(or attach facility receipt) Date
r
tfrrt .doc* `I�1 System Pumping Record#Page I of I
Commonwealth of Massachusetts
rolvn Of
N
4 { City/Town of No. Andover NO* ndo
A
• Ver
System Pumping Record
Form kfAR
r EP has provided this form for use by local Boards of health. Oth T- r ay e used, but the
information must be substantially the same as that provided here. Be cor i Lb' , check with your
local Board of Health to determine the fora they use. The System Purnpin l eoo � hmitted to
the local Board of Health or other approving authority within 14 Mays from the pumping slate in
accordance with 310 CMR 15.351,
A. Facility Information
5
Important:When
filling out forms 1. System Location:
on the computer,
1 Willow Street
use only the tab
key to move your Address
cursor-do not
use the return of Andover NSA 1
City/Town845
Sate Zip Code
2. System Owner:
Bake ' !' Joy .w
Name
{� SAME
Address(if different from location) ,�.Y. .w..Mm N....
itylTown Mate Zip Code — ..Y.
Telephone Number ry.. .. .
Pumping Record
Date of Pumping . Quantity Pumped: w....
Date sins
7
3.
Component: Cesspool(s) Septic Tank El Tight Tank Grease Trap
J.
E9,010ther(describe).
• NM••r
Y Effluent Tee Filter present? Yes No If yes, was it cleaned' El Yes No
}� . observed ndition of component pumped:
p p �
.... ,; All of this estimated
information is non-binding, valid only at the time of pumping.g. Not_T jble beyond the date move.
f 6. stern Pumped By:
Name vehicle License Number
1
S Development Corp. d l Stewart s Septic
Service
'i Location where contents were disposed:
Stewaffp Receiving ivin Facility, 20 So. Mill St., Bradford, MA o 1835
..... v. � See above
�• Signature of Hauler� Date
See above
Signature of Receiving Facility r attach facility receipt) Date
t form .doo•11112ystem Pumping Record•Page I of
Town
of Nofth
�L\ Commonwealth ofMassachusetts
•
Cif /Town o No. Andover
n '49System PumpingRecord
f #* FormHealth
Department
EP 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, chock 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 o. Andover MA 01
use the return . . ....
l e ityfrow w..,Y.�v.�.w.. State Code
2. SystemOwner:
tab
Name
SAME
Address if different from location)
ky Town State Zip Code
Telephone Number
B. Pumping Record
Date of PumpingDate 2. Quantity Pumped. aeon
i
f
3. Component: Cesspool(s) Septic Tank El Tight Tank Grease Trap
Other(describe):.
i
. Effluent Tee Filter present? El Yes EF14o If yes, was it cleaned' ❑ Yes !
i
r
. observed o dition of component pumped:
� ry Alf of this estimated
information is non-binding, valid only at the time of p pin , Not ro anslblo beyond the date above.
f
. System Pumped By-. .,-.-.,.
-j
Name vehicle License Number
B Development Corp. d/bla Stew rt's Septic
Service
i
. Location where contents were disposed:
Bt waErt. eooivin Faoilit,y, 2 Bo. MiII St., Bradford, IAA 01 3
J..w........
See above ..-, fir { . ...
-W....
.
... ......... ....
i signature of±Hauler Date
See above
signature of Receiving Facility or attach facility receipt) Date
f
t5form4.doe•I illSystem Pumping Record•Pave I of 1
Town
Of NOdh
Andover
Commonwealth of Massachusetts
{ 4 City/Town of No. Andover MAR
System Pumping Record
Form 4 HeaftolL)OPartMent
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 sane as that provided here, before using this fora, 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 of the tab Willow Street
key to move your Address
cursor No. Andover MA 01
use thereturn �..._._-:....
key. lty "own state Zip Code
. System Owner.
r
Bake I J
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: [:1 Cesspools El Septic Tank El Tight Tank El Grease Trap
:f ,�-. N
a/Other(describe),
4, Effluent Tee Filter resent? El Yes a No If yes, was it cleaned Yes No
. Observed condition of component pumped:
} co �
All of this estimated
information ation is non- Lindjng,valid p .1y at the time of p r Ln�of r spon it le b ore tie date above.
6. System Pumped By: .
Name Vehicle License Number
S Development Corp. 1 a Stewart's Septic
Service
7. Location where contents were disposed;
Ste rart's I eceivin _ F �lj1y So. Dill St., Bradford, MA 0 1
See above
Signature of Hauler' TM Date
_ See above
Signature of Deceiving Facility(or attach facility receipt) Date
r t for 4.doce 11/12 System Pumping record•Page I of`l
}
TO
Wn of NOrth Andov.
Commonwealth
City/Town of N . Andover M ,2
System Pumping Record
Form o�
EP has provided this fora for use by local Boards of Health. Other forms may be used, but the
information must be bstantaally the sane as that provided hero. 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 Willow Street
key to move your Address
purr not No. Andover 11A01845
use the return w. �.�. —
ey. City/Town State Zip Code
. System Owner:
r
Bake o
Name
SAME_
Address if different from location)
M .......... . .
ftyff own State dip bode
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2, Quantity Pumped. Gallons
. Cor ponert;......... ❑ Cesspools ❑ Septic Tank El Tight Tank El Grease Trap
Er6ther(describe);
. Effluent Tee Filter present's ❑ Yes ❑ No if yes, was It cleaned? ❑ Yes ❑ No
y Observed condition of component pumped:
� .,.,.,.. ._ . All of th is estimated
r bindin valid only at the time of
t information is on- ' � y +�... pumpin�. Not responsible beyond the t above,
. System Pumped By:
{ r -
a e Vehicle License Number
J S Development Corp. /b/a Stew rt's Septic
Service
. Location where contents were disposed:
7S7tewar" I eivin F oil it 20 So. Mill St. Bradford MA 6 3 ..........
., w 5
{{ i ._.__..__.. fee above ... ... ...w
Signature of Hauler Date
See above
Signature of Receiving Facility or attach facility receipt Date
t ferr .doe%11/12 System Pumping Record•Page I of I
i
Town
Of N06h AndOver
Commonwealth of Massachusetts
} City/Town of No. Andover MAR
System Pumping Record
Formal He t"F
Af Dep'
t
DEP 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 Beard of Health to determine the fora they use, The System Pumping record rust be submitted t
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CM 5.3 5 1, ,
A. Facility Infoimation
Important:When
filling out forms 1. System Location:'
0n the corr-puter,
(16 to
use only the tab
key to move your Address
cursor R do notNo. Andover MA01845
use the return
key,
, City/Town w.. State -.. Zip Code
. System Owner:
rah ,
_. 49 o
Name x
SAME
Address if different from location)
itrlTowo Sate Zip Code
Telephone Number
B. Pumping Record
EDO
1, Date of Pumping 2. Quantity Pumped:Date
GzA logs
Component: Cesspools Septic Tank Tight Tank El Grease Trap
D/010ther(describe):
4, Effluent Tee Filter resent' E] Yes EKNO If s eras it cleaned Yes 10
p ❑ �
. Observed condition of component pumped;
6 All of this s estimated
information is non-binding, valid only t of in . blot re ensible beyond the date above.
, System Pum ed By:
a e vehicle License lumber
&S Development Corp. d b/a Stet art's Septic
Service
7. Location where contents were disposed:
Ste rart's Receiving Facility, 20 So. Mill St., Bradford MA 01835
= See above
ignture of Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
r
t f rro .doc*11/12 System Pumping Record•Pave 1 of I
Town
do
Ve
Commonwealthof Massachusetts MAR "-4-.2025
.. City/Town of No Andover
P
' System Puy i Record � - DepcjjjrneF rm �
DEP 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 form they use, The System Pumping Record rust be submitted to
the local Board of Health or other approving authority within days from the pumping date In
accordance with 310 CMR 15.351,
A, Facility Information
Important:When
fil
la out Corr . System Location.
on the computer, 7
use only the tab
key to move your Address
cursor-do not
use the returnCity/Town State Zip Code
key.
. System weer:
r
Name
RAM
Our
Address if different from location)
o Andover MA
City/Town State Zip code
r
Telephone Number
B. Pumping Record r
. L
` . Quantity Pumped:
. Pumping Date Gallons
3, Component: Cesspool(s) Septic Tank ❑ Tight Tank Grease Trap
Other(describe);
. Effluent Tee Filter present? Yes if yes was IteedYet-,E No
f5. Observed condition omp e t pumped;
. System Pumped
7)
6
a e Vehicle Umn a Number
Stewale Septic 58 So Kimball St. , E radford MA
r
Company
. Location where contents were disposed:
20 $-0
JOL-st--j�Mt IM11
1gntur of Date
Signature of Recelving Facility(or attach facility r eelpt) - Date
7
i
f
}
t fbrm4,do +11Ji 2 System Pumping Record#Page I of 1
r
i
Town
Vh Andov
commonwealth of Massachusetts
MAR
c i y Town o N o. A d o e r � 4-2025
system Pumping
Y., Form
Ment
I 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 form they use. The System Pumping Record must be submitted to
the local Board of health cr other approving authority within 14 days,from the pu m ping date i
accordance with 310 CMR 15.351.
A. Facility Information
Important:when
filling out forms I. System Location:
on the computer,
use only the tab .......... vy
�..
�..
key to move your Address
cursor R do not No. Andover IAA 01845
use the return
fey, city "own State --..... Zi
p code
2. System Owner:
Name
SAME
Address(if different from location
City/Town state dip code
..............
Telephone Number
B. Pumping Record
1. e of Pumping .�. ......- . Quantity Pumped: alto
ns
3. Component: El Cesspool(s) Septic Tank E:1 Tight Tank El Grease Trap
Other(describe). _N
, Effluent Tee Filter present? Ej Yes n 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.ping Not responsible beyond the date above.
5, System Pumped y:
Name �.� Vehicle License Number
J&S Development Corp. d/b/a Stewarts Septic
Service
!
..........
. Location where contents were disposed:
' So. Mill St., Bradford M/l o1 8
r
�tewartf l Facility, m � ..� .�
' �....� See above
Signature of Hauler Date
See move
Signature of Receiving Facility(or attach facility receipt) Date
t
t
!
i t forr .dote 11/12 System Pumping Records s Paige I of
k
Town of NO*
Commonwealtho Massachusettsver
-A
City/Town o No. Andover
MAR
4,2025
System Pumping Record
F
Form 4 Ve
+C
D P has provided this fora for use by local Boards of Health. Other forms may be use but
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 date in
accordance with 310 CMR 15,351.
A, Facility information
Important:When
filling out forms I System Location:
on the computer,
use only the tab
� .� � � .. � �.. ,........ ........�.,,
ley to move your Address
cursor do not No. Andover MA , 01845
use the feturn City/Town state dip bode
ley.
2. SystemOwner'.
(3, .0
Name
r� SAME
Address if different from location)
!..w.........
. �...�. ...
lt}IToir State Zip Code
Telephone Number
B. Pump' ing Record ,T
r
1. Date of Pumping 2. Quantity Pumped; - --. .
Date Gallons
3. Component: Ej Cesspool(s) E:1 Septic Tarr El Tight Tanis w .^area 's
Other(describe), N.......� N
4
. Effluent Tee Filter present? ElYes No If yes, was it cleaned' ❑ 'e No
. Observed condition of component puny ed:
..ry .vv All of this estimated
information is non-bino6d, valid only-'at the time of pumping. Not responsible be yond the date above.
, system Pupped By-
Name Vehicle License Number
AS Development Corp* d/b/a Stewart's Septic
Service
7, Location where contents were disposed,
Ste t Leo lvit l of t � � ., hill St. Bradford, l'IIIA
y ..
See above
i i to f:'F Id UAW m Date
M
r
See above
Signature of Receiving eiving Facility r attach facility receipt) � Dame
t5torm .door 1 1 12 System Pumping Record•Page i of 1
1011vn NOM Ando
Commonwealth of Massachusetts
MAR
5 f{ Ff
City/Town of No. Andover 025
Sr
wSystem Pumping RecordHO
Ith De rt
Form 4
14 P
EP 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
focal 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 1 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important When
filling out forms I. System Location:
t
+ on the computer,
use only the tab
key to move your Address
cursor-de not No. Andover MA 01845
use the returnCity/Town State Zip Code
ley.
2. System Owner:
rib 1
Name
SAME
Address if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
I. Date of Pumping gate . Quantity Pumped: altos
3. Component: ❑ Cess ool El Se tic Tat ❑ Tight Tank ❑ Grease Trap
Other(describe . .. �.
t Effluent Too Filter present ❑ Yes 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.
. S st Pu rpeo
Name vehicle Licen a Number
S Development ent Corp. d b/a Stewart Septic
Service
7. Location where contents were disposed;
Stewapos l eceiv1n Facil1 ty So. Dill St., Bradford, MA 0 18 35
6/ fee above
Signature of Fla lr Gate
See abode
Signature of Receiving Facility(or attach facility receipt) Date
t form .d c• 11/12 System Pumping record•Page 1 of 1
Commonwealth o Massachusetts
City/Town of No. Andover
System Pumping Record , �
ll�
"..r
,.w o rm 4 �
Ve
d5 r
DEP has provided this form for use by local Boards of Health. other forms e� rh
t
e
�information rust a substantially the sane as that provided here. Before using this r � c with your
local Board of Health to determine the fora they use. The System PWpiqcj Record must be submitted to
the local Board of Health or other approving authority within 14 days ftm. j 'ng date In
accordance with 310 CM R 15,351. rtM
,,,t
A. Facility Information
Important When
filling out forms 1. System Location:
on the computer, �
use only the tab
key to mere your Address
cursor..do not o, Andover MA 01845
use the return
fey it Prow State Zip Cede
14
2. System Owner:
ray I { ,
0 V�. _.r..Y.v.. Nw.v..
Name
r1r SAME
Address if different from location)
City/Town date Zip code w.....�
Telephone Number
B. Pumping Record
nio
1. Date of Pumping
Date 2. Quantity Furnped. Gallons
3, component; Cesspools El Septic Tangy E] Tight Tank El Grease Tree
0111�0ther(describe):
. Effluent Tee Filter present? El lies Ea o If yes, was it cleaned? El Yes No
5. Observed condition of component pumped:
All of this estimated
information is non- irdinrlid onI et the time o u In f dot rposlle n the date above.
64 System Pumped y:
..M..:n{
Name
ne Vehicle License Number
J S Development Corp. d/b/a Stewart s Septic
Service
. Location where contents were disposed:
Stewa "s Recelvin Facility, 20 So. Mill St., Bradford, MA 01836
See above
Signature of Hauler Cate
See above
Signature of Receiving Facility r attach facility receipt) Date
t ferr 4.doe•11/1 yster Pumping Record•Paige I of I
7f�
Of 17
NOCommonwealth of Massachusetts
��
dover
City/Town of No,, Andover44AR
System Pumping Record
Form 4
J 9* Pa
tiF
lMdot
P has provided this form for use by local Boards of Health. Other forms may be ,
information ation 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 i
accordance with 310 CIVIL 15,351.
A. Facility Information
Important.,When
filling out forms 1. System Location:
on the computer,
I
. use only the#a f �
key to more your Address
cursor-do not Allover IVI �3 o
use the return . . ..
o �
.....�.�_ .........key, itylTovwrn State `p Code
2. System wrier:
Name
re ar SAME
Address(If different from location)
} ityTrown State Zip Cove .
;44
l
Telephone Number ..
E3. Pumping Record
. Date of Pumping Quantity r Pumped:
Date Gallons
3. Component: El Cesspool(s) El Septic Tank El Tight Tan Grease Trap
other"(describe).
. Effluent Tee Filter present? El Yes�No If fires, was It cleaned? El Yes 0 No
. Observed condition of component pumped:
All of thisestimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
, System Pumped By:
Name Vehicle License dumber
J&S Development Corp. d/b a Stewart Septic
Service
7. Location where contents were disposed;
Stew r ecivir g F pc ilit , 20 S . Dill St., Bradford, MA 01 33
C.
m.� See above C-� .
Signature of Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
t forrn4,da •11112
System Pumping Record•Page 1 of I
Commonwealth of Massachusetts Moo
VIXF M
City/Town of No. Andover 00ver
System Pumping Record
4
#,} .# Form 4
�f xt
EP has provided this form for use by local Boards of Health, Other fo �� I used but the
information ation must be substantially the same as that provide here. Before using with your
local Board of Health to determine the form they use, The System Pumping Record ord mus. 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,
VA S�—
use only the tab
3 key to move your Address
�
cursor-do not o, Andover M
I use the return o1
key. City/Town State Zip Code
2, stem
r Owner.,
Name
SAME
3 v.
Address If different from location _ Y v.....,w.
x
rCity/Townstate Zip bode
Telephone Number �...
2
B. Pumping Record
. Date of Pumping . QuantityPumped:
DateGallons
3. component; El Cesspool(s) El Septic Tank El Tight Tank El Grease Trap
Other describe : .�. .w.
4, Effluent Tee Filter present? El Yes Er No If yes, was it cleaned? Ej Yes El No
5
Observed dition of component pumped:
'r r
All of this estimated
} information is nor-bindin V lid oni at the tine of purl ire . Not responsible beyond the date above.
r . System Pumped By:
Name vehicle License Number
S Development Corp. dlb a Stewart Septic
Service
7. Location where contents were disposed:
SStewar' Receiving Facility, 2 So. Milli St., Bradford} !1!'�A 01835
S bee
f �: _.--
igna ure of Hauler Date
See above
Signature of Receiving eivin Fadflty or attach facility receipt) Date
t forrn ,doe•11 System Pumping Record ord*Page i of 1