HomeMy WebLinkAboutMay 2025 Bake N Joy Grease Trap - Septic Pumping Slip - 351 WILLOW STREET 5/2/2025 Commonwealth of Massachusetts I 0tv/7 Of
A_
Ity/Town of No. Andover 417dover
AIN
ysteIm Pumping ReIcord
A
111 14`6% orm at lyea
DIEP has provided this form for use by local Boards of Health. Other forms may It the
information must be substantially the same as that provided here. Before using this form,P490pith your
local Board of Health to determIine 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 1
A. Facility I nformation
Important:when
filling out forms 11. System Location:
on the computer,
351 use only the,tab Will,ow Street----. ..........
key to move,your Address
cursor-do not -No. Andover MA 01845
use the return
key. City/Town State Zip Code
tab 2. System Owner:
Bake �Jo
Name
Run SAME
Address if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gall.on.s
3. Component: El Cesspool(s) [I Septic Tank F-1 Tight'Tank Z Grease Trap
El
Sludge Other(describe)::
4. Effluent Tee Filter present? E:1 Yes [dNo, If Yes, was it cleaned'? E:1 Yes Ej No
5. Observed condition of component pumped:
SLUDGE All of this estimated
,information is non-bindini, valid onl at the time ofkyrpi n n N g., otre or�sible beyqqq!�he date above.
,
6. System Pumped By:
0-So Y1......
--------
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
...........
7. Location where contents were disposed:
eta Receiving, Facilj�y, 29 So. M,ill St., Bradford, MA 01835
OL S6 y\_ See above
Signature of Hauler Date
See above
Signature of Receiving Facility(or attach facility pt) Date
t5form4.doc*11112 System Pumping Record Page 1 of 1
Commonwealth of Massachusetts 17JAyn of,'Nofth Andover
wn of No., Andover
UN 4, ? 25
System Pumping Record
At Department
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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, 3,51 Willow streetu.
use only the tab,
key to move your Address
cursor-do not No. Andover MA 01845
use the return -....................... ............-®. ...............
key. Ci�ty/Town State Zip Code
2. System Owner:
Bake 'N' Joy
Name
SAME
Address(if different from location)
City/T'own State Zip Code
Telephone Number
B. Puw.
mping Record
1. Date of Pumping Quantity Pumped:
Date Gallons
3. Component: Cesspool(s) F] Septic Tank E:1 Tight Tank Z Grease Trap
Ej Other(describe): Sly. ge
4. Effluent Tee Filter present? E] Yes P,0"`N�o If yes, was it cleaned? Yes [:1 No
5. Observed c :Idition of component pumped:
SLUDGE All of this estimated
information is non-binding, valid only at the time of puTpi g. Not re��ponible beyond the date above._.__.__ _
6�. System Pumped
e,
zj7Z' 10
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewart's eceivinq Facility, 20 So. Mill St., Bradford, MA 01835
\j See above
Signature of Hau�lier Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc,p 11/12 System Pumping:Recordo Page 1 of 1
Com,monwealth of Massachusetts Town of Nodh Andover
M it y/Town of No. Andover
N 9 2025
System Pumping Record
Ar Form 4
Health Department
DIP 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 CIVIR 15.351.
A. Faci l ity Information
Important,:When
filling out forms 1. System Location:
on the computer,
use only the tab j
key to move your Address
cursor-do not No. Andover MA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
V W 04
( 10,
oe Name
rein
Address(if different from location)
.... ...... ...... ..........
City/Town ...... State.......... ... Zip Code
Telephone Number
B,. Pum ping Record',
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: Cesspool(s) El Septic Tank [I Tight Tank Hoo"O(Jrease Trap
t—(Iol AIL
Other(describe)". � r
4. Effluent Tee Filter present? El Yes 0 No If yes, was it cleaned? E Yes El No
5. Observed condition of component pumped:
'All of this estimated
information is non-binding, valid only at qLpq e e time
mping. Not responsible beyond the date above.
................. ........_ _
6. System Pumped By:
n1 I m s oin&
.............. ......... ..............................
Name %Ij Vehiclle License Number
J&S Development Corp,. d/b/a Stewart's Septic
Service
7'. Location where contents were disposed:
Stewart's Receiving Facility, �.q So. Mill St., Bradford, MA 01835
See above
Signature of Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt), Date
t5foirm4.doce 11/12 System Pumping Records Page 1 of 1
Town of North Ando
Commonwealth of Massachusetts
M
z City/Town of No. Andover
UN 4'
�025
System Pumping Record
Af 14 Forml 4 Depa
rtM e
DEP has provided this form for use by, local Boards of health. Other forms may be used, but the 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 cif Health oir other appirovi'ng, authority within 14 days from the pumping date in
accordance with 310 CAR 15.351.
A, iliy Information
Important:When
filling out forms 1. System Location,:
on the computer,
351 Willow Street
use only the tab .......... ...... .......
key to,move your Address
cursor-,do not N_.._.._.o. Andover MA 01845
use the return key. City/Town State Zip Code
l
2 System Owner:
Ag u
. Bake 'N'
po Name
SAM E
Address(if different from location)
City/Town State Zip Code
`telephone Number
B. Purnping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: E] Cesspool(s) E:1 Septic Tank E:1 Tight,Tank Z Grease Trap
.E] Other(describe): Sludge,
4. Effluent Tee Filter present? 0 Yes 5�/N(o if yes, was it cleaned? E:1 Yes Ej No
5. Observed condition of component pumped:
SLUDGE All of this, estimated
information is non-binding, valid only at the time of pum ing. loot responsible beyond the date above.
6. SysteM.Eymr,%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 iviesFacilit 1, 20 S.9. Mill St., Bradford, MA 01835,
See above
of Haul Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc* 11/12 System Pumping Records Page 1 of 1
Commonwealth of Massachusetts Town Of North 4ndo
fty/Town
.of No Andover
C
JUN 42025
System Pumping Record
Af 1,14 % Form 4 e
Pci
DPI has provided this form for use by lo H cal Boards of ealth. Other forms may be used, but the lient
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 CI 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, 351 Willow Street
use only the tab ................—
key to move your Address
cursor-do not No., Andover MA--. 01845
use the return City/Town State Zip Code
y.
2. System Owner:
�Utab
%1
Bake'N' Joy
P Name
A SAME
Address if different from location)
City/Town State Zip Code
...............
Telephone Number
B. Pumping Record
Gal
1 Date
1. Date of Pumping 2. Quantity Pumped: ..............lons
3. Component,* Cesspool(s) F] Septic Tank El Tight Tank Z Grease Trap
ED Other(describe): SIuqq-e-
4. Effluent Tee Filter present? 0 Yes El No If yes, was it cleaned? El Yes M No
5. Observed condition of component pumped.
-
SLUDGE All of this estimated
information is no�n-bindin , valid only at the time.of pumping. Not responsibl��_Peyond the date above.
...............
6. Systgro-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 Repeiv!,, Facility, 20 So. Mill St.,, Bradford, MA 01835
See above
nature -a ler Date
'00 .......... See above
... ........................
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doce 11112 System Pumping Records Page 1 of 1
Town Of A, 17do
Commonwealth of Massachusetts orth
JUN 4
City/Town of' No. Andover
-2025
System Pumping Record
,,r_
Form 4 Depart,,,
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the lit
information must be substantially the same as that provided here. Before using this form,, check with your
local and of Healthy to determine the form they usel. The System Purnping Record must be submitted to
the local Board of Health or other approving authority within 14 days from t�he plumping data 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 Willow .Street
key to move your Address
cursor-do not No. Andover MA 01845
use the return ...........
key. City/Town State Zip Code
tab
2. System:, Owner:
Bake NJlo,y
Name
SAME
.....................
Address(if different from location.......
ocation)
....... ..... ...................
Ci:ty/Town State Zip Code
............ ............
Telephone Number
131. Pumping Record
-1006
1. Date of Pumping 2. Quantity Pumped: .............
Date Gallons
3. Component: El Cesspool(s) [I Septic Tank Ej Tight Tank Z Grease Trap
El Other(describe): S I U
da
4, Effluent Tee Filter present? [_� Yes n/No If yes, was it cleaned? El Yes 0 No,
5. Observed condition of component pumped:
SLUDGE All of this estimated
information is non-binding, valid on t the time of pumping. Not, re§pqnsib_.Ie b nd the date above.
..........
6. System Pumped By:
C,0
Ti
Name Vehicle License Number
J&S Development Corp. d/b/a Stew art,'s Septic
-Service
7. Location where contents were disposed:
Stewart's Receiving Facility,_ 0 Sc. Mill St., Bradford, MA 01835
See above
�ig Hato re o H"a'uler Date
See above
Signat ure of'Receivinig Facill'ity for attach facility receipt) Date
t5form4.doce 11/12 System Pumping Recordo Page 1 of 1
Commonwealth, of' Mas,sachusetts NOrth Andove
C"Ity/Town of No. Andover
_mm.
System Pumping Record JUN 4 2025
Form 4
Af SIA
DEFT has provided his form for use by local Boards of Health. Other forms may be use?,q�'1tQ10tjt
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 3101 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 IMA 011845
use the return .......
key. City/Town State Zip Code
2. System Owner:
Bake 'N' Joy
lip Name
r err SAME
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
03
1. Date of Pumping 2. d:Quantity Pumped
G a I Ponsc
3. Component: El Cesspools) Ej Septic Tank El Tight Tank Z Grease Trap
El Other(describe): Sludgy
4. Effluent Tee Filter present? 0 Yes No if yes, was it cleaned? El Yes 0 No
5. Observed condition of component pumped:
SLUDGE All of this, estimated
information is non-binding, valid only at the time of,p_q_T _in S, Not responsible beyond the date above.
6 "y r,Syste y:
Pum ed, B
.............
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewart's, Receivi Fa0ity, 20 So. Mill St., Bradford, MA 01835
11107
See above
i e �a r Date
....�..See above
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc- 11112 System Pumping Recorde Page 1 of 1
it
Of IV
Commonwealth of Massachusetts
or
City/Town of No Andover
SUN
System Pumping Record
4
'f C iPippr
M r .0"�
J
11 h 4A s provided, this form 1 1 for 1 use by local Boards' �,.e�1 Health. e used,
11
1 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 forma 1. ,system Location:
on the computer,
use only the tab _...._._ 1 yl/illow,street
key to move your Address
cursor-do not No, Andover ILIA 01845
use the return . .... ._._ ...key. City/T'own State Zip Code
V
2.. System Owner:Q r�r
fake N' Jo
Name
roan SAME
Address(if different from location)
... ...
City/TownMate Zip Mode _... .... ..__�.
Telephone Number
B. Pumping Record
1. Date o�f Pumping bate Quantity 16 Gallons
3. Component: Cesspool a Ej Septic Tank [:1 Tight Tank Z Grease Trap
Other(describe): Sludge
4,, Effluent Tee Filter present? El YesE"ONo If yes, was it cleaned" El Yes El: No
5,. !observed co ition of component pumped
SLUDGE All of this estimated
information is non-binding, valid only at the time of pumping., Not responsible beyond the data above,
, System Pumped �yM
4
A-?�o
_.__ �_ ..._ � �..m �_......w_ �..... _..._.._..._
Name vehicle license Number
&S Development Corp, d/b/a Stewart's Septic
Service
7, Location where contents were.disposed:
20 So, bill St, Bradford, MA 01835
�to wa rt'� l�e c e i v n g_Facility,, �.__..._ .....__. �.�.__...... _.
1
1
See above "
t
.eY,nture of �_�.......�giHauler Gate
,fee ,above
� Receiving Facility. ._...___�
Signature of _..�.....
(or attach facility receipt) late
t
t
t5form4,doce 11/12 System Pumping record•Page 1 of I
�L
TOVIn Of jV ,
orth A dOl
Commonwealth of Massachusetts ver
City/Town of .No. Andover JtIN 42025
Wo System Pumping Record
Depart
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the 01 it
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 3,51 Willow Street
keyto move your, Address
cursor-,do not No. Andover MA 01845
use the return ......- ..............
key. City/Town State Zip Code
o 2. System Owner:
Bake `N'__Loy
Name
SAME
Address if different from location)
................ ..................
City/Town State Zip Code
Telephone Number
B. Pumping Record
0
I
11. Date of Pumping Date 2. Quantity P� .
umped: Gallb""ns. ....
3. Component: F] Cesspool(s) El Septic Tank Tight Tank Grease Trap
E Other(describe): ......... Sludge
4. Effluent Tee Filter present? [:1 Yes No If yes, was it cleaned? Yes [_1 No
5. Observed condition of'component pumped:
SLUDGE Al'I of this estimated
information is non-binding) valid only at the time of_p,umping. Not re§ponsibl,e beyond the date above.
6. System Pumped By:
Name Vehicle License Number
J&S Development Corp. d/b/a Stew art's Septic
Service
7. Location where contents were disposed:
' i -Stewart's Receivina Facility two So. Mill St.,, Bradford, MA 01835
See above
Signature of Hauler Date
See above
Signature of Receiving Facility or attach facillity receipt) Date
t5forrn4.doc* 11/12 System Pumping Recordo Page 1 of 1
Commonwealth of Massach usetts TOWn of iVorth AndWer
City/Towrl of No. Andover
mping Record JUIV 2025
System Pu
Form 4
At C
DE,P has provided this,form for use by local Boards of Health. Other forms may b6-JUqAaj"-
information must be substantially the same as that provided here. Befolre usi'ng this form, chec our
local Board of Health to determine the form they use. The System Pumping Record must be sub mitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1 System Location,:
on the computer,
use only the tab 351 Willow Street ..........
key to move your Address
cursor-do not No. Andover-- MA 01845,
use the return key. City/Town State Zip Code
2. System Owner:
1 0476
B,akeN' Joy
Name ........
MW 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) E] Septic Tank El Tight Tank 0 Grease Trap
El Other(describe)., Sl udge
4. Effluent Tee Filter present? El Yes 0 No, If yes, was it cleaned? E] Yes [:] No
5. Observed condition of component pumped:
SLUDGE All of this estimated
information is non-binding,__valid onily at the time of pumping. Not responsibli�byqnd the date above.
6. System Pumped'Bj:
tin
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
.Stewart's Recei.v� Faci'lity, 20 Sol, Mill St., Bradford, MA 01835
See above
Signature of Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc,o 11112 System,Pumping Record Page 1 of 1
Town Of IV
orth
�L\ Commonwealth, of Massachusetts rh d0 Ver
ityffownAndover 1JN 4,2025
An
W System Pumplong Record
Form, 4 h
Af
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 pumping date in
accordance with 310 CMR 15.351.
A. Faci l ity Information
Important:When
filling out forms 1 System Location,:
on the computer, 351 Willow Street
use only the tab ............ .......
key to move your Address
cursor-do not No. Andover '0 18 4 5
use the return State Zip Code
key. pity Town
2 ....... 2. System Owner:
tab
Bake 'NJoy
Name
rearn SAME
Address if different from location)
City/To an State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2,. Quantity Pumped:
Date Gallons
_.._...� .._..�
3. Component: E] Cesspool(s) E] Septic Tank Ej 'Tight Tank 0 Grease Trap
Other(describe): Sludge
4. Effluent Tee Filter present? 0 Yes /'-N'�o If yes, was it cleaned'? E] Yes [:1 No
5. Observed nd,ition of component pumped:
SLUDGE All of this estimated
information is non-binding, valid onl at the time of um ing. Not..resp above.
n s i b 1,e
In
6. System Pumped
Vehicle License Number
Name
J&S Development Corp. d/bi/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewart's Rece(vLing 2 So. Mill St., Bradford, MA015
0
See above
Signature of Hauler Date
See above
Signature of Receiving Facility or attach,facility receipt) Date
t5form4.doco 11112 System Pumping Record o Page 1 of 1
Commonwealth of Massachusetts 70MIln of IVOrth Andovu
City/Town of UN 4 2025
System Pumping Record
Form 4
Alt jePartt, nt
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'Hearth or other approving authority within 14 days from the plumping date in
accordance with 310, CAR 15.351.
A. ili Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab L
key to move your Address
cursor-do not M-oc& An 4wer MA
use the return City/Town State Zip,Code
key.
2. System Owner-
..........Name
NSAME
Address(if different from location,)
......................
Cilty/Town, State Zip Code
Telephone Number
B. Ing Record
I., Date of Pumping 2. Quantity Pumped':
Date Gallons
3. Component: El Cesspool(s) Septic Tank Tight Tank Grease Trap
El Other(describe):
4. Effluent'Tee Filter present? F1 Yes No If yes, was it cleaned? El Yes El No
5. Observed condition of component plumped:
All of this estimated'
information is non-binding_,_valid only(6lf the time of p in Not rep poq§ibq.1e beyond the date, above.
._yTp .IT
6. System Pumped Bly-
I
I f
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
k-
Stewar' Recqvingl-llllacility, 20 So. Mill St., Bradford, MA 01835
See above
'gnat of Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doce 11/12 System Pumping Record Page 11 of 1
Commonwealth of Massachusetts T9' V',1n Of Nodh Andover
City/Town of No. Andover
JUN 4 825
System Pumpoing Record
Form 4
ej DePa e In
DEP has provided this form foir use by, local Boards of Health. Other forms may be used, butt 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 pumpling 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 guilldle0
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town, State Zip Code
key.
2. System Owner:
tab
Bake 'N Joy
Name
Mon SAME
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping RecordiA.
1., Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: Q Cessp�ool(s) F-1 Septic Tank El Tight Tank Z Grease Trap
El Other(describe): Sludge
4. Effluent Tee Filter present? E] Yes, No If yes,, was it cleaned? Yes [I No
5. Observed condition of component pumped:
SLUDGE All of this estimated
-information is non,-binding, val'I'lid-,,only at the time of pumping. Not responsible beyond the date above.
6. System P ed By:
F
.............
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewart's Receivin Facility, 2,0 So. Mill St., Bradford, MA 01835
See above
r6(Rf,-'n a u I e Date
See above
...Hato reof Receiving Facility(or attach facility receipt) Date
t5f6rm4.doc,o 11112 System Pumping Recordo Page 1 of 1
Commonwealth of Massachusetts TQvvn Of North 4n1dV
C it o. Andover
System Pumping Record N
.2025
Form 4
t'-1ca I&
DEP has provided this form for use by local Boards of Health. Otherf854UITQ(W� A t le
. ,iLk
information must be substantially the same as that provided here. Before using this for ,V wi,th, your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14,days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 351 Willow Street
key to move your Address
cursor-do not No. Andover MA ........... 0,1845
use the return —._—_.-
key. City/Town State Zip Code
2. System Owner:
49:1
...........__
Bake N Joy.._._.
Name
fe&M
I I SAME
..........._...........
Address(if different from:location)
..........
City/Town State Zip Code
.............
Telephone Number
B. Pumping Record
o b
1. Date of Pumping 2., Quantity Pumped:
Date Gallons
3. Component: E:1 Cessplool(s) El Septic Tank Q T'ighit Tank Z Grease Trap
[:1 Other(describe): .............. Sludge
4. Effluent Tee Filter present? E] Yes 0 No If yes, was it cleaned? Yes 0 No
5. Observed condition of component pumped:
SLUDGE All of this estimated
�..._ation is non-biq0ip_j,..._vaIid_only at the time of puT ing. Not.respion:sible b�yopq the date above.
p:
6. System Purn id By:
..Name Vehicle License Nu_.,..
mbar
J&S Development Corp. d/b/a Stewart's Septic
-Service
7. Location where contents were disposed:
-Stewart's Rece in Facility, 20 So. Mill St., Bradford, MA 01835
See above
hat o puler Date
See above
..........Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doce 11/12 System Pumping Record Page 1 of 1
Commonwealth f Massachusetts TOwn Of North AndOye
City/Town of No. Andover
UN
S
41025 ystem Pumping Record
Form 4
Depa
DE P has provided this form for use by local Boards of Health. Other forms may be used, but"he lit
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 Purnping Record must be submitted to
the local Board of Health or,other approving authority within 1'4 days from the pumping date in
accordance with 310 CAR 151.351.
A. Facility Information
Important;When
filling out forms 1. System Location:
on the computer,
use only the tab 3,51 'willow Street
key to move your Address
cursor-do,not No., Andover-_ MA 01845
use the return _
City/Town State Zip Code .......
key.
2. System Owner:
Bale 'N'._49y
Name
SAME
Address if different from location)
....... .......
City/Town State Zip Code
Telephone Number
B. Pumping Recoird
1. Date of Pumping 2,. Quantity Pumped:
late Gallon�
3. Component: Cesspool(s) 0 Septic Tank Ej Tight Tank E Grease Trap
e
� Other(describe): ...... ....... Sl.d .
4. Effluent Tee Filter present? El Yes El No If yes, was it cleaned? Ej Yes El No
5. Observed condition of component pumped:
SLUDGE All of this estimated
-inform�ation is non-bindlqq, valid only at the time of pumpqq. Not responsibl� ��yqnd the date above.
6. System Pumped By: Z
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
-Service
7'. Location where contents were disposed.-
St so. Mill St., Bradford, MA 01835
See above
u ler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doce 11/12 System Pumping Record Page 1 of 1