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HomeMy WebLinkAboutJanuary 2025 Bake N Joy - Septic Pumping Slip - 351 WILLOW STREET 2/1/2025 Commonwealth of' Mas,sachusett,s Town of Nod Andover i own of M.No. An over FEB 3 2,025 System Pumping Record Form 4 Health DeIr fla DEP has provided this form,for use by local Boards of Health. Other forms may be red, nul nee t 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 th eI omputer, use oy the tab key to move your Address cursor-do not No. Andover MA 01845 use the return key. City/Town State Zip Code 2. System Owner: VV Name SAME, Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 3 1. Date of Pumping 2. Quantity Pumped: Date Gallons 3, Component: Cesspoo,l(s) F1 Septic Tank El T'ight Tank El Grease Trap 101, El Other(describe): ......... 4. Effluent Tee Filter present? El Yes El No If yes, was it cleaned? El Yes [:1 No 5. Observed condition of component pumped: All of this estimated information is non-bindle valid on�Ind at the time of pumping. Not responsible beyond the date above. 6. System Pu B ped By: ped Name Vehicle License Number J&S Dev I meat(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 See above Signature of Receiving Facility(or attach facility receipt) bate t5form4.doc# 11/12 System Pumping Record o Page 1 of 1 Town of North Andove Commonwealth of Massachusett_ _ s City/Town of '... No. An d over 40 _m FE8 System Pumping Record 32025 Form 4 ticfi DEP has provided this form for use by local Boards of Health. Other forms "I information must be substantially the same as that provided here. Before using thii,s forrni7, chop A 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 data in accordance with 310 CAR 15.351. A. Facility Information lmportant-When filling out forms 1 System Location: on the computer, use only the tab key to move your Address cursor-do not No�.Andover MA 01845 use the return Ci�tyfTown State Zip Code key. 10 10101� 2. System Owner: tab 0 Name 1 SAME ....... Al 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. Compo,lnent: El Cesspooll(s) El Septic Tank El Tight Tank [:1 Grease Trap 0 110e Other(describe): 4. Effluent Tee Filter present? Yes 0 If yes, was it cleaned? El Yes El No 5. Observed condition of component pumped: All of this estimated information is non-bi he sand the data above. 6. System Pumped By, e'll oq ---2L 'Name Vehicle License Number J&S Development Corp. d/b/a Stew art's Septic Service 7. Location where contents were disposed.* Stewar�s ReceivinU-_rFacjI So, Mill St., Bradford M, A 01835 z/ 11 00, 0 ep See above 10 ..........i gnature of Hauler Date See above Signature,of Receiving Facility(or attach facility receipt) Date t5form4.doco 11/12 System Pumping Recordo Page 1 of I I Commonwealth olf' Ma,ssachusetts 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 A/ key to move your Address cursor-do,not A Nxt Pit use the return ey City/Town State k . 76 tAl IV 2. S ystem Owner: # J .ox Name Address(if different from location) tit No Andover MA City/Town State Zip Code Telephone Number B. Pumping Record ............ 1. Date of Pumping .Chat 2. Quantity Pumped: Gallons 3. Componen"C"""', Cesspool(s) peptic Tank..' Tight Tank Grease Trap 010 0,01,00 100, Other(describe) ...... 1101"o-00,11 4. Effluent Tee Filter present.? E] Yes Ej No If yes, was it cleaned?. Yes No 5. 01 b erred co,dition of component pumped., 6,. System Pumped By: 000 111"';1 '10 Mme Vehicle License Number Stewart's Se tic,58, So Kimball St. Bradford,,MA Company 7. Location where contents were disposed: 20 So,,,,,Mlll St.,Bradford,MA Usignature of i-laul r Dhte signature of Receiving Facility or attach facility receipt) Date t5form4.doc,,11/12 System Pumping Record Page 1 of 1 Commonwealth of Massachusetts z 0 City/Town of No. Andover Systelm Pumping Record' Form 4 DE 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 plumping date in accordance with 3,10 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 018 use the return % City/Town liv key, 2. System Owner: State Bake "N' L Name V 7J I hffl I eu 44 1 SAM E Address(if different from location) 'n 91 'paftme city/Town State Zip Code Telephone Number B. Pumpling Record pool- AV 1. Date of Pumping --- 2. Quantity Pumped: Date Gallons, 3. Component: El Cesspool(s) El Septic Tank El Tight Tank El Grease Trap d''Po Oi00006i`h'her(describe): 4. Effluent Tee Filter present' Yes EY140 If yes, was it cleaned? Yes No 5. Obs"e" rved co,19dition of component pumped: 7 10 0 All of this estimated information is non-bind�ing, valid only at the time o um-P-T-9. Not responsible beyond the date above. 6. System Pumped By: ao, Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service ......... ....... 7. Location where contents were disposed: Stewaf,,Vs Receivin Fac,ilit ....20 So. Mill St., Bradford, MA 01835 .9 V7 W See above Signature of Hauler Date See above .......... Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc,, 11/12 System Pumping Record Page 1 of 1 Commonwealth of Massachusetts Ulty/Town of. No. Andover 5 System Pumpi�ng Record Fo,rm 4, At DEP has provided th�is 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 u�s,e. The System, Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pu mping dat e�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 0 use the return City/Town, ............ ...... State key. 0 n of Nd WCM 49 2. -System Own­er: Bake 'ICI' Joy EB Name Fre i wn A6 Address if different from location) e e p a Ci!tylTown State Zip Code Telephone Nlum,ber .......... B., Pumping Record 1. Date of Pumping 2. Quantity Pumpe�d: Date Gallons 3. Component.- Cesspool(s) 0 Septic Tank Ej Tight Tank Grease Trap o 0101110 01 00101 10001 e? KI Other(describe): 4. Effluent Tee Filter present? El Yes, Eb,N,o If yes, was, it cleaned.? El Yes D No 5. Observed con, ition of component pumped: CC,V, All of this estimated information is non-binding', valid onjy_�t th umping. Not responsible beyond the date above.,_ 6. S y yst,e Pumped By:11, o ........... Name Vehicle License Number J&S Development Corp. d/b/a. Stewart's Septic ,Service 7. Location, whore contents were disposed: Stewa Receiving Facility, 20 So. mill! St., Bradford, MA 01835 j;0007, See above signature of Hauler Date See above Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc,o 11/12 System Pumping Recordo Page I of I _ . mCommonwealth of Massachusetts TOWn Of Nofth Andover it awn of No. Andover FEB 3 22 ._ 5 System Pumping Record Form 4 D 1 1 99pt DE,P has provided this form for use by local Boards o or�s f Health. Other may e information must be substantially the same as that provided here, Before using this form, check wlthl 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 CIIIR 15.351. A. Facility Information Im,portant:When filling out forms 1., System Location:" on the computer, use only the tab key to move your Address cursor-do not No, Andover MA 01845 use the return key. City/Town State Zip Code 2. System Owner: Name tean SAME 01( Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Reicord 1- Date of Pumping Di to 2. Quantity Pumped: Gallons 3. Component: Cesspool(s) El Septic Tank Ej Tight Tank 0, Grease Trap, ' " O, ther(describe): J 4. Effluent Tee Filter present? El Yes Q.—No If yes, was it cleaned? El Yes El No 5. Observed co9dition of component plumped: C/ All of this estimated information is non-ojpdin , valid only at the time of pumping. Not responsible beyond; the date above. 6. System Pumped By 1p Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Stewq) s Receivin ._Facility, 20 So. Mill St., Bradford, MA 01835 101010,P allo 4 e4 .0 .11 See above 5 f Signature of Hauler Date See above Signature of Receiving Facility(or attach,facility receipt) Date t5form,4.doco 11/12 System Pumping Record Page 1 of 1 Commonwealth of Massachusetts M' a Town Ot North 4nd City/T'own of No. Andover ov. : e 5 r System Pumping Record Af 32025 DEP has provided this form for use by local Boards of Health. C. ay be used, but the information must be substantially the same as that provided here,rIA7r'f6G,n I r , check with your top local Board of Health to determine the form they use. The System Pumping Reco i, Wmitted to the local Board of Health o i r other approving authority within 14 days from the pumping date n accordance with 3,10 CMR 15,3511. 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. C w ity/Ton State Zip Code i 6 2. System Owner: tab c Bake ' 'NJ,oy ........... Name f AM SAME Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 100/ 1 Date of Pumping Date 2. Quantity Pumped: Gallons 3. Compon"ent: Ej Cesspool(s) F] Septic Tank 0 Tight Tank F-1 Grease Trap 1111�110, .001'00', Other(describe): ................. 4. Effluent Tee Filter present? Yes If yes, was it cleaned? E] Yes E No 5. Observed condition of'co,mponent pumped: All of this estimated information, is non-bIqdl_Rg valid only at the time of pumping. Not,repo yondnsible be the date above. ................. 6. System Pumped By, L( Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed:. StewqA's RecLn,eiy Facilit 20 So. Mill, St., Bradford MA 01835 g "'0( 00 Lo"O See above Signature of Hauler Date See above Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc,p 11/12 System Pumping Record•Page 1 of 1 i Comm:onwealth of Massach usetts City/Town of No. Andover System Pumping Record F+ rm 4 At 1q,,lb g 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 pumpling date in accordance with 310 CAM R 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 Nog-h—A-17. key to move your Address doyer cursor-do not No. Andover— MA 01845 ' use the return key. City/Town State FEB ZiXodie I b 2. System Owner: Z025 Oki 14 Bake 'N' Joy Name .......DepartMent SAME Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping, Record 0D I Date of Pumping Date 2. Quantity Pumped: G all o n s ........ 3. Component: F1 Cesspool(s) El Septic Tank F1 Tight Tank r-1 Grease Trap I Other(describe},: .......... 4. Effluent Tee Filter present? Ej Yes [:R/No If yes, was it cleaned? E] Yes E] No 5. Observed condition of component pumped: 'Jodw -t- All of this estimated information is non-bIqqleq, valid oni t the tune of umiping. Nqt onsi�ble.beyond' the date above. 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 Re ' ' Facility ceiviN _�O So. Will St., Bradford, MA 01835 ow.- '0000 See above n"nature o, Data See above Signature of Receiving Facility(or attach facility receipt) Data t5form4.doco 11/12 System Pumping Record.Page 1 of 1 Commonwealth of Massachusetts City/Town of No. lover System Pump"Ing Record orm 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 frorn 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 Willolw Street_ key to move your Address cursor-do not _N..q,...._.Andover M!A 01845 use the return ................. City/Town State ftde key. 2. System Owner: town 6? orth Andover Bale NJoy Name 2025 Address(if different from location) City/Town State Zip Co"de--' Telephone Number B,. Pumping Record C-7 1. Date of Pumping 2. Quantity Pumped: Date Gall ns 3. Component: El Cesspool(s) Septic Tank Tight Tank F1 Grease Trap Other(describe).- 4. Effluent Tee Filter present? 0 Yes 01 If yes, was it cleaned? 0 Yes El No 5. Observed condition of component pumped:-1-1) A, All of'this estimated information is non-binding, valid only at the time of pu�mping. Not responsible be e date above. beyond the 6. Syst Pump d B Na fn Fe _"vehicle Lice­n­s'e_Numbbr J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: S te w a r' vini, llity ?,r d, IAA 0 18 35 See above Sig Hato re of u r' Date See above Signature of Receiving Facility(or attach facility receipt) Date t5form4.doco 11/12 System Pumping Record o Page 1 of 1 Commonwealth of Massachusetts i Tows of No., Andover System Pumping Record' 0 Form 4 DE,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 apiprov,ing authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1 System Location: on the computer, use only the tab 351 Willow Street —..-. key to move your Address cursor-do,not No. Andover MA 01845 use the return City/Town State Zip Code key. System Owner: rib Bake 'N' Joy Name SAME Address(if d ifferent from location) FEB——......3 2025 City/Town State h Healt : Zip,Code"'I Telephone Number 11*'r%A4 Ll I IV-11-nt--- B. Pumping Record 1. Date of Pumping 2. Quantity Pumped Date Gallons 3. Component- Cesspool(s) Septic Tank Tight Tank Grease Trap Er Other(describe): 4. Effluent Tee Filter present? Ej Yes t&No If yes, was it cleaned? El Yes 0 No 5. Observed condition of component pumped:: ("( All of this estimated i9lv - information is non-bindin valid only at the time of um in Not responsible beyo nd the date above. ............ 6. System Pumped 777 101, .......... Name Vehicle License Number J'&S Development,Corp. d/b/a Stewart's Septic -Service 7. Location where contents were disposed: StewaV,Ii Receiving Facility, 20, So. MIilIl St., Bradford, MA 01835 .. 01 yaw d ......... See above 11 Signalure of Hauler Date See above Signature of Receiving Facility or attach facility receipt) Date t5form4.doc,*11/12 System Pumping Record Page I of I Commonwealth of Massachusetts City/Town v._ er System Puym Record Form 4 A 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 CIS R 15.351. A. Facility Information Important:When filling out forms, 1. System Location: on the computer, use only the tab ...... 351 W i I I ow S,t re e t key to move your Address cursor-do not No. Andover MA 0!1845 use the return City/Town State key. tab 2. System Owner: Bake 'N' Jo Name rear SAME, Address... (if different from_location,) ----------- h - DopaaMenA .......... City/To n State Zip Code Telephone Number B. Pumping Record 1 Date of Pumping Date 2,. Quantity Pumped: Gallons 3. Component: Cesspool(s) Septic Tank F� Tight Tank El Grease Trap / I if"I". ­­5� / 'z�' /z, F1, Other(describe): 4. Effluent Tee Filter present? 0 Yes No If yes, was it clean�ed? E Yes F] No 5. Observed: condition of component pumped: 0 61 All of this estimated info rmatian is, non-binding, valid onl at the time of pum ping. Not re psible beygnd_the date above. 6. System Pumped By: 000,71 .......... Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Sept,ilc Service 7. Location where contents were disposed: Stewar .s Receivin Faci lity, 20 So. Mill St.,, Bradford, MA 01835 _g 01 el C See above ........... gnature of Hauler""" Date See above Signature of Receivi'ng Facility(or attach facility receipt) Date t5form4.doco 11112 System Pumping Records Page 1 of 1 Commonwealth of Massachusetts City/Town of NoI. Andover System Pump"Ing Record Form 4 kr q lb DEP has provided this form for use by local Boards of Health. Other foIrms may be used, but the I 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 tea the local' Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CM 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab 35.1-Willow Street key to move your Address cursor-do not No. Andover MA 0118451 use the return ......... ...... .......... key. City/Town State d f fp Town ot Andover 2. System Owner: Bake 'IN' Jqy Name SAME Address if different from location) Health DelpartmenA City/Town State Zip Code Telephone Number B. Pumping Record )1j,,00 e�ll (111111N, 0 1. Date of Pumping 2. Quantity Pumped: Date Gallons 3. Component: El Cesspool(s) El Septic Tank El Tight Tank Ej Grease Trap IF Other(describe): 4. Effluent Tee Filter present? 0 Yes M/No If yes, was it cleaned? 0 Yes E] No I 5. Observed condition of component pumped: ot"") All of this, estimated `0 information is non,-bindi valid on at the"time of pumping. Not responsible beyond the date above. 6. System Pu 7 ed By: m N" , Name vehicle License Number J&S Development Corp. d/b/a SteIwart's Septic Service 7. Location where contents were disposed: ,Stewart's Receivip9facility, 20,ISIa.'­'Mill St., Bradford, MA 01835 Ile 00 '1100001 See above '00011 ignaturel "I a u It Date i�imp See above Signature of Receiving Facility(or attach facility receipt) Date t5form4.doco 11112 System Pumping Record Page 1 of 1 Commonwealth, :nCity/Town of No. Andover System Pumpl"nlg Record Form 4 A, DEP has provided this farm 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 Hof Health to determine the farm 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 CIVIR 15.351.. A., Facii Information Important:When tilling out forms 1. System Location: on the computer, 351 1�lvi I lcvu street use only the tab key to move your Address cursor do not No. Andover MA01845 use the return -®_.....�...___ _. _. _ __ ._..._ key, City/Town n ;state w � 0 2. System Owner: Town, d Andover Bake '_ .. . ._w1 .N..d .............�_ _. �..__.__ Name FE-8 NOR SAME Address,cif different from location Health nt City/Tovvn ._.........�._..._..... State ._... _..._ _ dip Code. .... .:�. .. .__........._ ......_ _..._.._.. Telephone Number B. Pumpling 1. Gate of Pumping �.___... _....... 2. Quantity Pumped: Cate hallo s 3. Component Cesspools El Septic Tank 0 Tight Tank El Grease Trap Other(describe): _.. _.....: __ _._ _ ...._..... 4. Effluent Tee Filter present' 0 Yes No If yes, was it cleaned' El: Yes El No 5.. Observed condition of component p roped: L,) . All of this estimated information . t responsible _,, __. t above. �� non-bindin , valid are at the t �of um, . �r�rn�c�, Not rep �on�lble beyond the date . System burn ed By: C,T Name vehicle License Number J S Development Corp. d bla Stewart's Septic Service '. Location where contents were disposed: Stewart's Receiving Facil' , 20 Sao. Mill St., Bradford, MA 01835 M See above of Mauler Late See above Signature of Receiving Facility(or attach facility receipt) Gate t5forrn4.doc• 11/12 System Pumping Record Page 1 of 1 Commonwealth of Massachusetts City/Town of No. Andover System Pumping Record Form 4 Af S4 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 local Beard 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 Wil,low Street key to,move your Address cursor-do not _No. Andover MA 01845 use the return _7( key. I City/Town State Own of Nofih Code tab 2. System Owner: AndOver ,V C Bake 'N' 49y Name 3-2-025 SAME Address(if different from location) City/Town State Zip Code Telephone Number Pumping Record 1. Date of Pumping ..._ Date 2., Quantity Pumped: Gallons 3, Component: El Cesspools,) Septic Tank Tight Tank Grease Trap Ej Other(describe): 4. Effluent Tee Filter present? 01 Yes(E N o If yes, was it cleaned? R Yes El No 5. Observed: condition of component pumped: 01 All of this estimated information is, non-binding.,_-valid only at the time of umping. Not res onsibl!��qnd thedate above. _p p 6. System Pumped _l 61 Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Stewar Receivin Facility, .1%. Mill St., Bradford, MA 01835 01 ......... ........ 01 See abo v e Shure of Hauler Date See above Signature of Receiving Facility(or,attach facility receipt) Date t5form4.doc4, 11/12 System Pumping Record Page 1 of 1 Commonwealth of' chi wC,ity/Town of No. Ando yQ0 System Pumping Record rr Af C EP has provided this form for use by local Beards of Health. Other forms may be used, but the information must be substantially the same as that provided hare. Before Busing 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 CA R 15.351. A. Facility Information Important:When filling out forms I. System Location: on the computer,use only the tab _._ 5 Willow Street _...M.�. _�_.. . key to move your Address cursoir-do not No. Andover MAC 01845 use the return .� .....�.. ...n.... key. City/Town Mate _ Zip Cody tab 2. System Owner: Town of Noifth Andover Bake 'N' 4qy Name .SAME ,Address if different from location): EB J Mate Z' Code in Dcpaffr�ent Telephone Number B. Pumping 0 1. Cute of Pumping �_.._.__ 2. Quantity Pumped: __ �.._.._ Nate Gallons 3, Component: El Cesspools El Septic Tank Ell flight Tank 0 Grease Trap Other(describe): _... 4. Effluent Tee Filter present? 0 "Yes No If yes, was it cleaned? "Yes 0 No 5. Observed condition of co, ponent pumped: All of this estimated infarmati n is non-b i nd i n vVid an l y_ the time �f um i g. N_ot res p"onsible be e�nd the date above. . System P m ped y Dame _....�__ .... ._..._.. �...._ _�.__�._ ._....�__._...... ._ vehicle License Number ,J&S Development C cirp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: `tewart's Receiving Facilit �O SCE. Mill St., Bradford, MA 01835 See above at of N4auler Date See above Signature of Receiving Facility(or attach facility receipt) [date t5form4.doce 11/12 System Pumping Record.Page 1 of 1 Commonwealth of' Massachusetts 'ity/Town of No. Andover z 11M System Pump"Ing Record % Form 4 DEP has provided this form for use by local Boards of H�ealth. 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 CM R 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 Town of iVOrth An ji� Name................ SAME Address if different from location) City/Town Staie--HiOal Zip Code th De ....Pciqment Telephoner umber B. Pumping Record lope,_> -3 cjc 1. Date of Pumping Quantity Pumped: Date Gallons 3. Component,: E:1 Cessplool(s) El Septic Tank 0' Tight Tank Ej Grease Trap ED,olbther(describe): L 4. Effluent Tee Filter present? Yes [:1 to If yes, was it cleaned? Yes No 5. Observed condition of component pumped: All of this estimated information is non-binding, valid onl the time of i ray on ihl l yonol Ihe date above. 6. System Pumped BX�, 01 Name Vehicle License Number __ �_.._ ... .... .__.._........ J&S Development,Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Stewar"9 Receiving Facility, 20 So. Mill St., Bradford, MA 01835 c See above Signature of Hauler Date See above Signature of Receiving Facility(or attach facility receipt) Date t5form4.doco 11/12 System Pumping Record Page I of 1 Commonwealth of Massachusetts City/Town of No. Andover System Pumpl"ng Record Form 4 A0 q DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substanitial'l'y 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 olf Health or other approving authority within 14 days from the plumping date in accordance with 3101 CIVIR 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: Town Of jV0 to Bake Joy rth A adav Name SAME Address if different from location) J-.2025 ............. Zip Code City/Tow n StateNe-ah iDqp,) Telephone Number B. Pumping Recoird 1. Date of Pumping 31 0­1 de-S 2. Quantity Pumped: Date Gallons 3. Component: El Cesspool(s) 0 Septic Tank El Tight Tank El Grease Trap U Ej Other(describe).- 4. Effluent Tee Filter present? [:] Yes r XNo If yes, was it cleaned? [:1 Yes E:1 No 5. Observed condition of component pumped: cl All'of this estimated information is non binding, valid only t the time of pump'�ng. Not re§pqp§sibIe beyond the date above. 6. System Pumped By: Name Vehicle License Number J&S Bevel pmen,t Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed,-. 'Stewart's Receivin Facilitv, 20 So,. Mill St., Bradford, MA 01835 See above—..—. Signature of Hauler Date See above Signature of Receiving Facility(or attach facility receipt) Date t5form4.doce 11/12 System Pumping Record o Page 1 of 1