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Home My WebLink AboutMarch 2025 Bake N Joy - Septic Pumping Slip - 351 WILLOW STREET 4/3/2025 Commonwealth of Massachusetts Town of North Andover City/Town of No. Andover System Pumping Record APR - 3 2025 Form 4 DEP has provided this form for use by local Boards of Health. Oth(Hr 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 No. Andover MA 01845 use the return .............. ---------- key. City/Town State Zip Code U.6 2. System Owner: % Name ietwn SAME Address(if different from location) ............................ City/Town State Zip Code ......-------------- Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped. - kl-) Date Gallons 3. Component: F-1 Cesspool(s) F-1 Septic Tank El Tight Tank F Grease Trap ID/Other(describe): -.....-J-afn J� ...... ----------- ----- 4. Effluent Tee Filter present? F-1 Yes Rf No If yes, was it cleaned? ❑ Yes E] No 5. Observed condition of component pumped: n006 -- 5 11 All of this estimated information is-non-bindiKJvalid only at the tir64 of pumping. Not responsible beyond the date above. 6. System Pu ped J'(0 41 Le- a Vehicle License Number D velopment 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 ature 7off Date See above Signature of Receiving Facility(or attach facility receipt) Date—----- t5form4.doc- 11/12 System Pumping Record-Page 1 of 1 Commonwealth �� QW� m�8�_ ��C��l�l��[l\�M��u/ / ^�/ w/��[�/ /i]��{� -' *v /VMyf6 � -�/��//0YlN�� ' of -�'uv ��|��YY ��Vyl ^^/ fp System Pumping Record ��U ��u�� n ��U�� xn��n � APR �� /mr _ _ _ ^v�J Form 4 DEP has provided this form for use bv local Boards ofHealth. Other forms m -4A information must bo substantially the same ao that provided here. Before using this form, nh 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 31OCPWR15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, key to move your Address cursor-""not No� Andovor MA 01845 �mmam�m key. City/Town State Zip Code 2. System Owner: Name SAME Address(if different from location) uty/rnwn State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 3, 2. Quantity Pumped: ------- Date Gallons 3. Component: El Cesspool( F-1 Septic Tank El Tight Tank El Grease Trap ffO�or(deechbe): --- 4. Effluent Tee Filter present? El Yes0"No |f yes, was it cleaned? R Yes E] No 5. Observed crdition of componentpumped: All of this estimated information is non-binding, valid only at-the time of pum tg_. Not responsible beprid the date above. O. System Pumped By� � - � �� Name Vehicle License Number J&S Development Corp. d/b/aGtovvart'aSeptic Service 7. Location where contents were disposed: Stew es Receivi_ _g_Facility, 20 So. Mill St., Bradford, MA 01835 See above Signature of Hauler Date See above Signature of Receiving Facility(or attach facility receipt) Date 15funn4.duo` 11/12 System Pumping Record^Page 1of1 �� —'' �Y /�0p�� Commonwealth �� An Massachusetts ��' ^^��7��[l\8/��/u . ^^/ /v/��/ /U�5^=`�� ' '»�Y///»�//OY1k�u° ��'fV7T��n of `�^ ��o Pumping Record � �� n �00�U�� u��nu* '^ « �� " ~, ^"�� . Form 4 DEP has provided this form for use by local Boards of Health. Other forms may information must bo substantially the same eethat provided here. Before using this fomn. ��0 local Board of Health to determine the form they use. The System Pumping Record must be submitted to the |ooe| Board of Health or other approving authority within 14 days from the pumping dote in accordance with 310CPNR15.351. A~ Facility Information Important:When filling out forms 1. System Location: vn the computer, use only the tab key m move your xoomoo oumor-dvnm use the return key. City/Town --- -- — — _ System Owner: Name Address(if different from location) No Andover MA City/Town State Zip Code Telephone Number B. Pump~ng Record 1. Qaba of Pumping '3h Id",Date/ 2� Quantity Gallons 3. Component El Cesspool(s) E7 Septic Tank Tight Tank [] Grease Trap Other(describe): - - - 4. Effluent Tee Filter present? E] Yen a~Ko |f yes, was itcleaned? Yea [l No 5. Observed c7ditionof component pumped: G. System Pumped Name Vehicle License Number 8tmwart'e Septic 5OSn Kimball St. BradfordN1A Company 7. Location where contents were disposed: ' 20S | St.,Bradford,MA �� 3��DV��|+� m� K8��C�� nf��' Commonwealth ,~. Massachusetts~^.~~ _.. w/ /�U/[� ��' �� /r�� ' "'wuv�g ��|T�Y � No. Andover System Pumping Record��.�� x U��k�� nx��o ^� APR _� �0yF F��F�M �� ^,�^ _ �~_ �� DEP has provided this form for use by local Boards of Health, (]ther��M��"�»ay information must ba substantially the same aothat provided here. Before us|ng--~~A�FKA'��tith your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the |ooe| Board of Health or other approving authority within 14 days from the pumping date in accordance with 31OCN1R15.351, A, Facility Information Important:When filling out forms 1. System Location: on the computer, key mmove your Address cursor'do not No. Andover MA 01845 use the return key. City/Town State Zip Code 2. System Owner: C tw Name SAME Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1 Date 2 Quantity Pumped:� Date � � Gallons 3. Component: Cesspool( R Septic Tank El Tight Tank R Grease Trap [T Other (deooribe). 4. Effluent Tee Filter present? [l Yea []l�o |f yes, was itcleaned? E] Yes Fl No 5. Observed co itionnf component pumped: All of this estimated information is non-binding, valid only at the time of pumping. Not respons d the date above. 0. System Name Vehicle License Number J&S Development Corp. d/b/a Stevvart'sSepUc Service 7. Location where contents were disposed: StewaX�Receivinq Facility, 20 So. Mill St., Bradford, MA 01835 . - �/_1111; - /v� See above Signature of Hauler Date See above Signature of Receiving Facility(or attach facility receipt) Date U5fonn4.doc- 11/12 System Pumping Record`Page 1of1 �� Commonwealth ��fK��ss��C�hus��ffs /Q�O Of North ��k�� '+`^r� f '�'=°^°/ ��|��/ o ��[l ��/ X System Pumping Record APR 00u� _ �,25 For DEP has provided this form for use bv local Boards of Health. Other foN information must beoubebantiuUy the same ee that provided here. Before using this fo!m,0" 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 310CK8R15.351. A, Facility Information Important:When filling out forms 1. System Location: on the computer,use only the tab �//u� key tn move your xddmau cursor'do not No. Andover MA 01845 use the return key. City/Town State Zip Code IU�� 2. System Ovvnec J. Name GAME Address(if different from location) Qty[Tmwn State Zip Code Telephone Number B. Pumping Record � ~q' �4— �^ ��/� 1. Da of Pumping Date ' ' 2. Quantity Pumped: a�lono 3. Component: El Cesspool(s) F] Septic Tank F-1 Tight Tank F-1 Grease Trap R 0(her(deaoriba): -- 4. Effluent Tee Filter present? El Yes B,.-Nn |f yes, was itcleaned? R Yes E] No 5. Observed c diti f componentpumped: All of this estimated information is non- nding, valid only at the time of pAmRi rqlNot_re o s bi sp�n ible beyond the date above. O. System Pumped By: � � Name Vehicle License Number J&G Development Corp. d/b/a8bawmryaSeptic Service 7. Location where contents were disposed: Stew, Signature of Hauler Date See above Signature uf Receiving Facility(or attach facility receipt) Dote t5fonn4.Uoo' 11/12 System Pumping Record^Page 1ufi Commonwealth of Massachusetts Town Of NO*Andover >� City/Town of No. Andover System Pumping Record APR - 3 2025 Form 4 DEP has provided this form for use by local Boards of Health. Other forms may e �1 information must be substantially the same as that provided here. Before using this form, check with,yo r 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, r ((b U 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 r 2. System Owner: Name ratan pu 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 'No If yes, was it cleaned? ❑ Yes ❑ 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. 6. System Pumped y Y p Vehicle Name Ve 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 — ❑ - Signature of � � _See above Si t -• "� a '�" C. g 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 7bvv;,? ®� � City/Town of No. Andover Andover System Pumping Record API - 3 20 Form 4 25 DEP has provided this form for use by local Boards of Health. Other forms &I!P �ne ut the information must be substantially the same as that provided here. Before using this local Board of Health to determine the form they use. The System Pumping Record must T!b!"itteN 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 No. Andover MA 01845 use the return - — .........................-..._.....--_._.. key. City/Town State Zip Code 2. System Owner: �l-GGtJ�e Name — e � SAME — ------------- ----- Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: G Ins- -- — 3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: d All of this estimated information is non-binding, valid only at the Ime of pumping. Not responsible beyond the date above. 6. Sys m Pump d B me ( Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Stewart's n�Fac' ' I St., Bradf A 01835 .__. .... -..-- ._... .._........ — —. —.__. r• See above ................._ Signature o uler Date See above Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1 TOV,n of iVorth And Commonwealth of Massachusetts over City/Town of No Andover APR ` 3 2025 aSystem Pumping Record Form 4 0alth Departm DEP has provided this form for use by local Boards of Health. Other forms may be used, but the �n� 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 cursor-do not use the return City/Town State Zip Code key. 2. System Owner: �fJ Name retwn Address(if different from location) No Andover MA City/Town State Zip Code Telephone Number B. Pumping Record an it 1. Date of Pumping Date 2. Qu t y Pumped:p Gallons 3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 6. Sys71;( mped By: 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 of Hauler -- Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 mfK�_ ��j��VV��|f� nfK��B��o w8�� ~�Commonwealth ,~. Massachusetts ~^°= �~"rVK/Mk�u~ ��' of -,u« ��|T�/ | �P�/�� ^^/ APR over ��ste�� Pumping Record '" '` � � �� = " �� _ ~v2J Form 4 DEP has provided this form for use by local Boards of Health. Other information must be substantially the same as that provided hone. Before using this form. nheohwitqKr local Board of Health to determine the form they use. The System Pumping Record must be submittedto the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310CK8R 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, ( 1_ �enn�mo�o �/ ' LV key Vo move your Address cursor-do not No Andover MA 01846 em use the tu � key. u/n«/»wn State Zip Coda 2. System Owner: V 011h /V Name SAME Address(if different from location) State 27ip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: Gallons 3. Component: D Cesspool(s) R Septic Tank M Tight Tank Grease Trap 2f Other(doacribe): 4. Effluent Tee Filter present? || Yes LJ/No |f yes, was itcleaned? Yen R No 5. Observed condition ufoompo t d 05) - All of this estimated information is non-bindir� , v ij/ I e timeipj um Not responsible beyond the date above. 6. System Pumped B NamZr' Vehicle License Number J&S Development Corp. d/b/a Stevvod'n Septic Gamioe 7. Location vvhena contents were disposed: 8tevvart'e Receiving Facility, 28 So. K4i|| St., Bradford, MA 01835 See above n Date gn.®r AZee,�;�- See above Signature of Receiving Facility(or attach facility receipt) Date t5form4.doo^ 11/12 System Pumping Record`Page 1of1 Commonwealth of Massachusetts Town Of North Andover City/Town of No. Andover PR - 3 System Pumping Record A 2025 Form 4 Healtil DEP has provided this form for use by local Boards of Health. Other forms may be us DeRPaMent 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 CIVIR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, ll use only the tab W 4 6j ............... key to move your Address cursor-do not No. Andover MA 01845 use the return key. City/Town State Zip Code 2. System Owner: tab 1 c� r� t _�, ----------- ----------- Name rerun 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) F-1 Septic Tank F-1 Tight Tank 0 Grease Trap '12/Other(describe): 4. Effluent Tee Filter present? ❑ Yes 01,40 If yes, was it cleaned? F Yes El No 5. Observed condition of component pumped: a ax)cj- s I L)4R, All of this estimated information is non-bindinig, V lid only at the time umpin . Not responsible beyond the date above. -------------- ..................... 6. Sy!st�e�rnpecl By:Rt ........... NO Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Stewart's Re!,c i'r F ' , Mill St., Bradford, MA 01835 _acility, 20 So__ See above Wrn-a t u re Date See above ............ Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc- 11/12 System Pumping Record-Page 1 of 1 -- ri//WUVer Commonwealth m� %8 Massachusetts �pD � � ?�c wC�F�F��V��/u / w/ ^v"��C�/ /U��~��w APR � ^"w �� ' f|T�Y U C��[1 ^�/ ' He� � �� System Pumping Record it �� 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 ae that provided here. Before using this form, check with your |ooe| 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 31OCK8R15.351. A~ Facility Information Important:When filling out forms 1. Gynbam Location: on the computer, use only the tab -357 key to move your Address cursor'do not No. Andover MA 01845 ret urn key. City/Town State Zip Code 2. System C}vvner: 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: r-1 Cesspool(s) Fl Septic Tank Tight Tank El Grease Trap VI/Other(describe): 4. Effluent Tee Filter present? F] Yee EY No If yes, was it cleaned? [l Yee [] No 5. Observed condition ofoomponent p m d _qnd the date above. 6. System Pumped B Vehicle License Number J&S Development Corp. d/b/a Stevvart'aGoptio Service 7. Location where contents were disposed: Stavvart'e Reouivin F i|it 20 So. K8i|| St Bradford, K8AO1835 See above jg::�e:-c f a u e r Date See above Signature of Receiving Facility(or attach facility receipt) Date {5form4.duo` 11/12 System Pumping Record^Page 1of1 To Wn r".rA I �L\ Commonwea!,o ssachusetts Town of North Andover of City/Town V System Pumping Record APR - 3 2025 Form 4 DEP has provided this form for use by local Boards of Health. Other f+[0efftpgA,4 . the information must be substantially the same as that provided here. Before using his I GMyour 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 Z key to move your Address cursor-do not use the return City/Town State Zip-Code key. 2. System Owner: VQ Name relwn Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Da, 2. Quantity Pumped: Gallons 3. Component: El Cesspool(s) 0 Septic Tank E] Tight Tank ❑ Grease Trap E] Other(describe): 4. Effluent Tee Filter present? F-1 Yes',O-No If yes,was it cleaned? ❑ Yes E] No 5. Observed,condition of compo nent pumped: 6. Syste6oumped By. 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 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 17 OW Of System Pumping Record Form 4 1VO*417do ver DEP has provided this form for use by local Boards of Health. Other forms may be d but the information must be substantially the same as that provided here. Before using th roc e.sttth your local Board of Health to determine the form they use. The System Pumping Record must be itted to the local Board of Health or other approving authority within 14 days from mping date in accordance with 310 CIVIR 15.351. oepa A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab 1' key to move your Address cursor-do not use the return City/Town State Zip Code key. 2. System Owner:retr A) Name Address(if different from location) No Andover MA City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping b 2. Quantity Pumped: Datel Gallons 3. Component: E] Cesspool(s) E] Septic Tank E] Tight Tank I�21"GreaSe Trap F-1 Other(describe): 4. Effluent Tee Filter present? E] Yes No If yes,was it cleaned? E] Yes 0 No 5. Observed onclition of component pumped: 6. System,P0'mped By Name Vehicle License Number Stewart's Septic 58 So Kimball St. Bradford,MA Company 7. Location where contents were disposed: 20 SoMill St.,Bradford,MA Signature of Hauler bate Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc-11/12 System Pumping Record-Page 1 of 1 Commonwealth of Massachusetts Town ofNph� = City/Town of No Andover ndoVer System Pumping ecor AP Form 4 R 3 2025 DEP has provided this form for use by local Boards of Health. Other ' used, but the information must be substantially the same as that provided here. Befor"usin t Wed your local Board of Health to determine the form they use. The System Pumping Record must be 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 use the return City/Town State Zip Code key. 00 2. System Owner: f Name �eaan Address(if different from location) No Andover MA City/Town State Zip Code Telephone Number B. Pumping Record Q 1. Date of Pumping DateC 2 Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap [Other(describe): 4. Effluent Tee Filter present? ❑ Yes �rNo If yes,was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pum ed: 6. S stem Pu ed By- - )'' 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 L-)s gnats Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 Commonwealth Massachusetts^*��VV��/u / w/ ,v'��/ /U�� row/' `� Ahth ��, ��'+`�/�- f ' ^'/WDL�� |`�' n ��\�/�� / ^�� System Pumping Record APo �� n ��U�� n��n � ' '� "? �� `"/J Form 4 Health DEP has provided this form for use by local Boards of Health. Other forms may be used, information must be substantially the same as that provided here, Before using this form, check'VN�� 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 31OCyWR15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, //^ use on�the�U " ' ' '-~' key to move your Address cursor-do- No Andover VIA 01845 use the n�um � City/Town State Zip Code key. 2. System Owner: GAME 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 F-1 Cesspool(s) F Septic Tank F Tight Tank Grease Trap Other (describe). � - 4. Effluent Tee Filter present? 0 Yes B No |f yes, was itcleaned? F-1 Yes [:1 No 5. {}beemad condition of componentpumped: All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. O. System Pumped By: Name Vehicle License Number J&G Development Corp. d/b/a 8tevvort'o Septic Service 7. Location where contents were disposed: Stew�ary;g Receiving Facility, 20 So. Mill St., Bradford, MA 01835 hl� —-S..................- See above Signature of Hauler Date See above Signature of Receiving Facility(or attach facility receipt) Date t5fonn4doo^ 11/12 System Pumping Record^Page 1uf1 ` ��[��O]��yV��|f� (�� &8��U��f�� _� ' .~ ." . . Massachusetts~��,= /Uk�� n�A/.-~ ��' of od Andover '' "` /V�/T� �n�� `~'�x' ' ^~~^' ' ~' ' ` ' `'/uWk9�� s�� ~�� ' System Pumping Record �P0 Form 4 APR 0o y — -� ^v�� DEP has provided this form for use by local Boards ofHealth, Othe used, but the infnnnadonnouatbeoubabanUaUy the same ao that provided here. refflu�� with your local Board of Health hn determine the form they use. The System Pumping Recor� nn��atmittedto the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 31OCyWR15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, ��- ` use only the tab '~ v' '`/ key to move your mmmoo ovmnr-do not No Andover MA 01845 usothevemm � key. City/Town State Zip Code 2. System Owner: Name SAME Address(if different from location) --------------------- utyl/mwn State Zip CodeTelephone Number B. Pumping Record 1. Date of Pumping Date 3 -d 2. Quantity Pumped: 3. Component: E] Cesspool(s) F� Septic Tank F Tight Tank El Grease Trap _�' �� Other(deaoribn): 4. Effluent Tee Filter present? F] You ZNo If yes, was it cleaned? [l Yee [l No b. Observed condition of component pumped: information is non-binding,(vdlid only at the tim4lof_,pumping. Not res onsible be ond the date above. O. System Pumped B Name Vehicle License Number J&S Development Corp. d/b/a Sbavvart'a Septic Gen/ioa 7. Location where contents were disposed: Stewart'Stewart's Receiving_Faciky, 20 So. Mill St., Bradford, MA 01835 See above OnatireREej Da-See above t5fonn4.goc^ 11/12 System Pumping Record`Page 1of1 �Ukkmn�8�^" ` vv �yWy7hA�_ r~��nV�e��|fh of Massachusetts '~'�0/�k�° '� �^ ��. C] � (I�7 | �� ^^/ No. Andover ��D � APR ^� � �0vc System Pumping Record "�� Form 4 Pa OEP has provided this form for use bv local Boards of Health. Other forms may beusYJ.«AQMe 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 31OCPWR15.351. 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 No� Andover MA 01845 use the pamm key. City/Town Stab Zip Code 2. System Owner: Name SAME Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date ofPumping Date - 2� Quantity Pumped� ||ono 3. Component: Cesspool(s) El Septic Tank El Tight Tank El Grease Trap 0,-0(her(deeoribe): 4. Effluent Tee Filter present? D Yes |f yes, was itcleaned? F-1 Yes El No 5. Observed o diti f componentpumped: (,("" All of this estimated information is non-binding, valid onl_v_at the time of pumping. Not responsible beVond the date above. 6. System Pumped By� � Name Vehicle License Number J&8 Development Corp. d/b/m Gtevvart'e Septic Service 7. Location where contents were disposed: Stewart's0eceiving Facility, 20 So. Mill St., Bradford, MA 01835 011 See above Signature of Hauler Date See above Signature u[Receiving Facility(or attach facility receipt) Date row Commonwealth ,�� &�Massachusetts `' Cf/Vnrf� `��D]��/u / �/ ^m��/ /�� ^`°u/ ��' . rV/[�)L*�~ y� f`//�- f �" ��' / C��[l ��/ ,�� System Pumping Record �� " ��K�D�KD ,n��uu �� ?�r ~ ~ ~~ �»�J Form 4 �� DEp has provided this form for use by local Boards of Health. Other forms m�0 information must be substantially the same aothat provided here. Before using this,fo��'«6��K��with your local Board of Health to determine the form they use. The System Pumping Record must besubmitted to the local Board of Health or other approving authority within 14 days from the pumping de[m in accordance with 31OCK8R15.3S1. ' 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 No� Andover MA 01845 use the n�um key. City/Town State Zip Code 2. System Owner: %ow 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 El Cesspool(s) El Septic Tank F-1 Tight Tank El Grease Trap 121"Other (deooribe): --^ - 4. Effluent Tee Filter present? R Yes iJ/No |f yes, was itcleaned? [l Yes 0 No 5. Observed c nditionf componentpumped: �"" l",, 7 All of this estimated information is non-binding valid only at the time of pumping. Not re --,Arespc��e ond the date above, 0. System Pumped By: —Name Vehicle License Number J&S Development Corp. d/b/a Sbsvvart'o Septic Service 7. Location where contents were disposed: "Stewar", See above,— signature of Hauler Date 8�� above t5fonn4don^11/12 System Pumping Record`Page 1of1 i Commonwealth of Massachusetts Town °fN City/Town of No. Andover °� �` n�0�er System Pumping Record APR 4 _ Form 4 2025 DEP has provided this form for use by local Boards of Health. Other forkt�y) d, but the information must be substantially the same as that provided here. Before using thi ith your local Board of Health to determine the form they use. The System Pumping Record must be su itted 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: �ov 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: ry / /� I t V/✓ I ----- Name .. rarrn SAME Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping -Date 2. Quantity Pumped: �IlonP 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap [Other(describe): µh - ---- 4. Effluent Tee Filter present? ❑ Yes �/Nio If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped:s/0 . All of this estimated information is non-bindir4g_ slid only at the time �umping__Not responsible beyond the date above. 6. System Pumped By: Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Stewart's Receiving Facility, 20 So. Mill St., Bradford, MA 01835 See above Zeof 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 � ��l0O��|l\�/��/u / ��/ /v/��/ /i]setts of City/Town f ��/ / C��yl ��/ '~ 41 ��s�� ~�� System Pumping�� Record ^ —~ O�m^ FK�K004 "��' DEP has provided this form for use by local Boards ofHealth. Other tAR information must be substantially the same eo that provided here. with your |oou| Board of Health to determine the form they use. The System Pumping Rec submitted to the |000| Board of Health or other approving authority within 14 days�om the punnpi6�~M accordance with 31OCk8R 15.351. ~^0r A. Facility Information Important:When filling out forms 1, System Location: on the computer, /i`' `�� //*�� use only the�b ~ v =' key ho move your Address cursor'do not No Andover MA 01845 mm use the tu � City/Townhay� City/Town State Zip Code 2. System Owner: Name SAME Address(if different from location) � City/Town State Zip Code Telephone Number B. Pumping Record � 1. Date ofPumping �Date2. Quantity Pumped: Gallons 3. C [| Cesspool(s) El Septic Tank R Tight Tank El Grease Trap �] Other(describe). --- 4. Effluent Tee Filter present? E] Yea E]~No |f yes, was itcleaned? r-1 Yea F-1 No 5. Observed colidition of componentpumped: e,4 All of this estimated information is non-bind(ppvalid only_at the time ofpurnpin"ot responsible beyond the date above. G. System Pumped B Name Vehicle License Number J&S Development Corp. d/b/e 8tewart'aSeptio Service 7. Location vvhenecontents vvenediapoeed� StewVr!s Receiving Facility, 20 So. Mill St., Bradford, MA 01835 Go88bOvH ^~�� ~c�� /�-- - ^ -- 5eeabovo Commonwealth of Massachusetts Town of'VOrth AndoVer City/Town of No. Andover 2 System Pumping Record APR - 2025 Form 4 Hoaltl) 3 199, DEP has provided this form for use by local Boards of Health. Other forms may 40,7"te 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 CIVIR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, �n VA 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 ietrn SAME Address(if different from location) City/Town State Zip Code --------------- Telephone Number B. Pumping Record 1. Date of Pumping 3 2. Quantity Pumped: Date Gallons 3. Component: F-1 CesspIool(s) R Septic Tank F-1 Tight Tank E] Grease Trap 2/ __:� a Q-WAX Other(describe): llv .................. 4. Effluent Tee Filter present? R Yes U/No If yes, was it cleaned? R Yes 0 No 5. Observed condition of compopent pumped:, 15/ocw— All of this estimated information is non i ing, valid onl at t6 e ofpumping_ Not responsible beyond the date above. 6. S y st ej X(d' ............. Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed: Stewart's Re ' *ceivin lit-Y, 205o. Mill St., Bradford, MA 01835 - ............ ...... See above .................... ....... dWailer Date See above Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc- 11/12 System Pumping Record-Page 1 of 1 �� Commonwealth fK�Massachusetts �U�� ofA�. ��]��[l��/�/ ' ��/ /v/��/ /U��1� ''' v/ /VU7yh � '+w/lF f '^'^xln/�~k�u~ ��|`�/ / ��yl ��/ '�w^�v System Pumping Record APR —3 �� "2J Form 4 DEP has provided this form for use by local Boards ofHealth. Other rr information must bo substantially the same oo that provided here. Before using thislft th your local Board of Health to determine the form they use. The System Pumping Record muetbe submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 31OCPNR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab - key 1p move your xuureno cursor-do not No. Andover MA 01845 uoothnmtum key. City/Town State Zip Code 2. System Owner: �� Name SAME Address(if different from location) -- City/Town State Zip Code Telephone Number B. Pumping Record 1. Date ofPumping Date 2. Quantity Pumped: Gallons � — 3. C Fl Cesspool( F-1 Septic Tank n Tight Tank El Grease Trap Ell~Dthor(deacribe): 4. Effluent Tee Filter present? F] Yea L]~W|o |f yes, was itcleaned? El Yee El No 6. Obse rved conAition of component pumped: ,J All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. S. System Pumped 0 21 Name Vehicle License Number J&G Development Corp. d/b/e Stevvart'sGeptic Service 7. Location where contents were disposed: Ste ' Receiving Facility-?059�!-Mill St., Bradford, MA 01835 See above Signature of Hauler Date See above Signature of Receiving Facility(or attach facility receipt) Date t5fonn4.doc^ 11/12 System Pumping Record^Page 1nf1