HomeMy WebLinkAboutJuly 2025 - Septic Pumping Slip - 351 WILLOW STREET 7/31/2025 1 To Wn Of North .r
Co mmonwealth of M'assach usetts It A I
fluOver
M City/Town of No. And over
AUG I
System Pump"Ing Record 1 Z025
For,m 4
Healt
DEP has provided this form for,use by local Boards of Health. Other forms may�vb""Mgtjj
information must be substantially the same as that provided here. Before using this form, chelcrwith 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 CMR 15.351.
1
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab ......... ............. ------
key to move your Address
curer-do not -No. Andover MA 01845
use the return 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 of Pumping 2. Quantity Pumped: 0 C
Data Canons
I Component: El......... Cesspool(s) Septic Tank 0 Tight Tank El Grease Trap
ro
Other(describ
4. Effluent Tee Filter present? 0 Yes No if yes, was it cleaned? [:1 Yes El No
5. Observed condition of component pumped:
All of this estimated
-information is non-binding, valid, only at the time of pumping-.-Not responsible beyond the date pbqye,
6. System Pumped By:
.............
Name Vehicle License Number
Ji&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where,contents were disposed.-
Stewart's Receivina Facility, 20 So. Mill St., Bradford,1 MA 01835.
I/
See above
......... .......
Signature of Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.d'oco 11/12 System Pumping Records Page 1 of 1
Commonwealth of Massachusetts Town of 1vorth
A do IIfN
City/Town of No. Andover Yur
� �
System Pumping Kecoru A
UG
%k, Form 4
DEP has provided this form for use by local Boards of Health. Other V0q@W*%i, d ut the
I, t Is V
information must be substantially the same as that provided here. Before using this ith your
'qtitte�d to
local Board of Health to,determine the form they use. The System Pumping Record must mbesu
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 I nformation
Important:When
filling out forms 1 System Location: is
on the computer, A)
use only the tab ..............
key to move your Address
cursor-do not No. Andover MA 0184
............ 5
use the return City/Town state Zip Code
key.
tab
2. System Owner: VU
Name
Non SAME
Address(if different from location)
_.��
..........................
City/Town State Zip Code
Telephone N�umber
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: F El Septic Tank 0 Tight Tank E Grease Trap
I Cesspool(s)
Other(describe): _..� __ __
4. Effluent Tee Filter present? D Yes [.2 No, If yes,, was it cleaned? F-1 Yes E:1 No
5. Observed condition of component pumped.-
2 Cs 0 10V All of this estimated
information is non-binding, valid y Not re ond the date above.
onl _�t the time of puTp����s�qpLs�i.ble bey
6. System Pumped By:
6-0 ............
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewart's Receiving......Facilit 1 20 So. Mill St., Bradford, MA 018 5
Ot-S-� ':f6"S See above
Signature of Hauler Date
See above
. . ..........
Signature of Receiving Facility(or attach facility receipt), Date
t5form4.doce 11/12 System Pumping Record,Page I of I
Town of Nodh Andover
Commonwealth of Massachusetts
City/Town of No Andover AUG 1 , 2025
System Pum�pl"ng Record
Form 4 80alth 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 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 No. Andover ...... MA 01845
key. City/Town State Zip Code
2. System Owner:
tab
Name
SAME
Address(if different from location)
City/Town State Zip Code
Telephone Number
B., Pumping Record
4'
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: El Cesspool(s) Ej Septic Tank Tight Tank Grease Trap
Other (describe):
4. Effluent Tee Filter presentEes ] �
6 If yes, was it cleaned? El Yes El No
5. Ob, erved condition of component pumped:
If 01
d
All of this, estimated
information is non-b�inding, valid only at the time qf_Rqmpjp_g- Not.1a nsible b��nd the date abcve
6. System Pumped B y:,,,,,,,,
0—1— 7>
o0olo
..........
Name Vehicle,License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewart's Receivin cility, 2,0 Sc. Mill St., Bradford, MA 01835
...........
1%,
110,
See above,
Signature of Hauler, Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doce 11/12 System Pumping Recorde Page 1 of 1
� Commonwealth of Massachusetts
TOwn
rah
y w City/Town of No.Andover
}-
System Pura in RecordAUG
Form 4 �
U'l.�I �y B
DEP has provided this form for use by local Boards of Health. other a but the
information must be substantially the same as that provided here. Before using sed fr* with your
local Board of Health to determine the form they use. The System Pumping Record must be su bmitted 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 _ t
key to move your Address
cursor-do not
use the return City/Town _ F State Zip Code
key.
2. System owner:V utg
.F7
Name ---.-------__�_� `
retra�
Address(if different from location)
No.Andover MA _
City/Town State Zip Code
Telephone Number
B. Pumping Record _.�..__�._... .__��._..�.. ..��_...�
-7 q
1. Date of Pumping pate 2. Quantity Pumped: Cal ons
3. Component: Cesspool(s) [ Septic Tank [ Tight Tank [, Grease Trap
[Vother(describe): �Sl QJ&P
4. Effluent Tee Filter present? [—] Yes No If yes, was it cleaned? D Yes [] No
5. observed condition of component pumped:
6. System-,Pu ed B
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
.... .. .........
Si of H er Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doce 11/12 System Pumping Record•Page 1 of 1
IP r" A- 1 1
0070"
uommonweaIII of Massachusetts
'ity/Town of No. Andover Town of Nod Andover
z
System Pumping Record AUG I I Z025
Form 4
DE,P has provided this form for use by local Boards of Health, Othe e used, but the
information must be substantially the same as that, provided here. WbuffAWOMM"twith 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 3110 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 0�
key to move your Address
cursor-do not -No. Andover MA 01845
use the return City/Town State Zip Code ....................
key.
2. System Owner:
t�Qtab
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. Comiponent.- El Cesspool(s) Septic Tank E] Tight Tank El Grease Trap
Other(describe): ..........
4. Effluent Tee Filter present? El Yes, 9"�N�o If yes, was it cleaned? E] Yes 0 NO
5 Observed condition of component pumped:
All of this estimated
information is non-blindi nl sp�onsib �Ayon
n,.g valid o at the time of pumping....Not re le b d the date above.
6. System Pumped By:
................
le Lic n se N u mber
Name 2 V e�i
J&S Development Corp. d/b/a Stewart"s Septic
Service
7. Location where contents were disposed:
-Stewart's Recei�vin . Facility, 20 So. Mill St., Bradford, MA 01835
_S'
-See above:
I -Signature of HauV Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc,p 11/12 System Pumping Record Page 1 of 1
Commonwealth of Massachusetts
z
U 0 City/Towrl 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 CIVIR 15.3511.
A. Facility Information,
Important:When
filling out forms 1. System Location:
on:the computer, aft
use only the tab
key to move your Address
cursor-do not -No., Andover M - MA 01845
use the return 11 ............
key. City/Town State Zip Code
2. System! Owner:
Name
Run awn,
SAME
Address(if different from location)
......... ......
City/Town State Zip-C--ode
Telephone N'umber
B., Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3, Compo'on,nt: Cesspools) Septic Tank E] Tight Tank 0 Grease Trap
O
/*ther(describe).-
" ..........................
4. Effluent Tee Filter present? E Yes U 0 If yes, was it cleaned? 0 Yes E:1 No
5,. Observed co dition, of component pumped:
7 All of this estimated
information i`s"non-binoigg, valid oR��a the time of_ppjpping. Nqt re§pqnsib e beyand the date above.
6. System P mp d By:
Name: Vehicle Lic rns,e Number
J&S Development Corp., d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stew rt' Receiyi�F�qility.,20 So. Mill St., Bradford, MA 01835
0?
See above
Signature o Hauler" Date
See above
Signature of Receiving Facility(or attach facility receipt) —Date-—--
t5form4.doc,o 11112 System Pumping Record Page 1 of 1
Commonwealth of Massachusetts go .
Town 0
t1h A
z City/Town of No. Andover N01
yr
System Piumping Record
Form 4 AUG
DFP has provided this form for use by local Boards of Health. Other ke used, but the
information must be substantially the same as that provided here. Biefore9 op heelwith your
local' Board of Health to determine the form they use. The System Pumping Record mu fitted to
the local Board of Health or other approving authority within 14 days from the pumping 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 ................ ..............
key to move your Address
cursor-do not No. Andover MA 01845
use the return key. City/Town State Zip Code
2. System Owner:
teh
c_
Name
SAME
Address(if different from location)
............ ....... ..........
w .
City/Ton State Zip Code
Telephone plumber
B. Pumping Record'
0#
ld~. 0006
0/0
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: El Cesspool(s) El Septic Tank El Tight Tank El Grease Trap
of
alo bthr(d escri be): 6, S . ......
4. Effluent Tee Filter present? Yes [0.-,No If yes, vas it cleaned? 0 Yes E] No
erved9ondition of component pumped:
All of this estimated
information is non-bindlnq, valid 991y at the time of pumping, Not rl�sponsible beyond the data above.
6. System Pumped By,:
'00
Name Vehicle License Number
J&S Development Corp, d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Ste cart s Regei Mill St., Bradford, MA 01835,
See above
Signature of Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
t5fo,rm4.doco 11/12 System Pumping Record Page 1 of 1
n of h AndoVer
Commonwealth of Massachusetts
City/Town of No. Andover
AUG 11825
System Pumping Record
Form 4
At
HeaRl-h
DE P has provided this form for use by local Boards of Health. Other forms may be AVY,91,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,
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.
tab
Name
rtrr 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) 0 Septic Tank El Tight Tank 01 Grease Trap
0'other(describe): Ro
4. Effluent Tee Filter present? Ej Yes 111-4o If yes, was, it cleaned? El Yes 0 No
5. Observed condition of component pumped:
All of this estimated
information is non-binding, valid oqly the time of pump ng....Not responsible beyond the date above.
6. System Pumped By:
...............
\J
oo� 11 6-,
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
-Stewart's, Receivinq_�acil..qK, 20 So. Mill St., Bradford, MA 01835
.............................
� 00,0
401 10 O ell 0
10 See above
1
Signature of Hauler Date,
See above
............
Signature of Receiving Facility(or attach facility receipt) Data
t5form4.doce 11/12 System Pumping Record Page 1 of 1
Commonwealth, of Massachusetts TOWn of Nodh AndOver
City/Town of NoIT_
. Andover
_ .
AUG I
System Pumpl"ng Record
Form 4
Af v4* Healti'l Depc@rtMent
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 3101 CM R 15.351.
A. Facil ity 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:
$1 Utahu.
Name
Ufl
SAME,
Address,(if different from location)
City/Town State Zip Code
Telephone Number
B, Pump lin Record
7 -7,
1. Date of Pumping Date 2. Quantity Pumped: Gallon s
3. Component: El Cesspool(s) E Septic Tank El' Tight Tank El Grease Trap
- I" Of
>0101� /
( -`
41 1, ,11"
.....................
El Other(descri be): 100117, '0,0
4. Effluent Tee Filter present? E:1 Yes El 060 If yes, was it cleaned? Yes Ej No
5. Observed condition of component pumped:
All of this estimated
Information is non-binding, valid only at the time of n �No� r q§pqfj�.e yond the date above.
6. System Pumped
1115
Name Vehicle License Number
J'&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
,Stewart's Recejiving F..aci..li y 20 So. Mill St.; Bradford, MA
,Ole
Alp/ 100
4,01111", 1 See above
Signature of Hauler gate
See above
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc,o 11/12 System Pumping Recordo Page 1 of 1
To VVn 0 f No rt 17
Co�mmonfwealth of Massachusetts, h do
M An V City/Town of No dover
tq A'UG 11 202%5
System Pumplong, Record
Form, 4
Ar 14 Health De,pa
r1m
DEP has provided this form for use by local Board's of Health, Other forms may be used,,, buRPI
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 I nformation
Important:When
filling out forms I System Location:
on the computer, 6
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
% tab 2. System Owner:
Name
rn SAME
Address(if different from location)
City/Tolwn State Zip Code
Telephone Number
B. Pumping Record
VOW'
1. Date of Pumping 2. Quantity Pumped: ........
Date Gallons
3. Component: El Cesspool'(s,) Ej Septic Tank � Tight Tank E] Grease Trap,
111"'d
/11........... ...
Other(describe): . .........
4. Effluent Tee Filter present? Yes 1z1.00`Nf6`- If yes, was it cleaned? El Yes El No
5. Observed core�lition of component pumped:
6 If 14-1(
All of this estimated
information is non-biP4!qgL.valid 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_facili�y MA 01835
............ .20 So. Mill St., Bradford!
4100",
31,
?
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
#v vi NOM Andover
Commonwealth of Massachusetts AUG 112,025
,Z City,/Town of No. Andover
4
0
V
>
Systeml Pumpl*ng Record Health Department
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, 6)
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
tab 2. System Owner:
( 01
Name
[elm
Address(if different from location)
............
City/Town State Zip Code
Telephone Number
B. Pumpi'ng Record
1. Date of Pumping 2. Quantity Pumped: .......
Date Gallons
3. Compo nt: El Ces,s o0l(s) El Septic Tank El Tight Tank 0, Grease Trap
7/7
70ther(describe)!:
4. Effluent T'ee Filter present? E] Yes If yes, was it cleaned? El Yes El No
5. Observed condition of component pumped:
cy ue All of this estimated
information is non-��ioing, valid opl�at the time of pumping. Not rep e_"qnd the date above.
6. System Pumped By:
...........
a m Te Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewart's Global, Environmental, LLC
420 ,,1, MiIJ St.,, Bradford MA 01835
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
Tows of North Andover
LN Commonwealth of Massachusetts
AUG
City/Town of No-Andover
rp r
0
C
W
System Pumping Record
Department
Form 4 Health
At V
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 31 o SMR 15.351.
A.Tacility Info rmation
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab �� �tlet
_
rx-
key to move your Address �
cursor w do not
use the return City/Town � _ �_ Sta. ............... ...........
te � Zip Code .._
key.
2. System Owner:
tab
Name
re�r,n
Address(if different from location)
No.Andover MA
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) ❑ 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. System Pumped By:
Jb _
Name Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill St Bra A
Si re f Haule Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc►11/12 System Pumping Record Page 1 of 1
9
Commonwealth of Massachusetts Town of Nod Andover
City/Town of No. Andover
AUG 2025
System Pumping Record
Form 4
Health 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 you�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 1,5.351.
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
ly tab 2. System Owner:
Joy
Name
RAW
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Recorms
1 Date of Pumping Date 2. Quantity Pumped: Gallons
3, Component: El Cesspool(s) El Septic Tank El Tight Tank El Grease Trap
14,
-r4
Other(describe): ;11
4., Effluent Tee Filter present? El Yes, F-1 No If yes, was it cleaned? E:1 Yes Ej No
5. Observed co dition of component pumped:
All of this estimated
.information, is non-!�in jpg, valid only_at the time of hum le beyond the date above.
6. System Pumped By:
C
Name r meF�1,
a Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewart's Global Environmental, LLC
20 �0. Kill St.,,Bradford A 01835
Ji
See above
SiOature of H" uler' Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc* 11/12 System Pumping Record Page 1 of 1
1W I I IVIVI U I ril luvvUr
Commonwealth of Mass,achlusetts AEG 2,025
ZI
&A Cr /Town of No.And r
>
19 Sys tem Pumping Record Heall'th Department
Form 4
:Af
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 CM R 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computert
use only the tab
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code
tab 2. System Owner:
Address if different from location)
NoAndover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1., Date of Pumping '1,
2. Quantity Pumped: 010
Date(&of7— Gallons
3. Component: E] Cesspooll(s) Septic Tank Tight Tank Grease Trap
................
P0.111 Other (describe):
4. Effluent Tee Filter present? Yes NC ,No If yes, was it cleaned? Yes No
5. Observed cop�lition of component purniped-
6. System Pumped By:
lkoe"
..........
Name Vehicle License Number
Stewart's Se tic 58 So KiImball St. Bradford,MA
Company
7'. Location where contents were disposed:
20 Sol.-Mill St.,Bradford,MA
ell
00/1
Sig ature of Hauler Date
S,ignature of Receiving Facility(or attach facility receipt) Date
t5form4l.doca 11/12, System Pumping Record a Page 1 of 1
Commonwealth of Massachusetts 7,0Wn0fN0
AndoVer
City/Town of No. Andover
A System Pumping Record AUG 11202%5
Form 4
At
DEP has provided this form for use by local Boards of Health. Otherl1fo t the
information must be substantially the same as that provided here. Before using this florm,watwith your
local Board of Health to determine the form they use. The System Pumping Record miust 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 Informati o n
Important:When
filling out for 1 w 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
I 2. System Owner:
V oab
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
7 5
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: Cessp�olol(s) F1 Septic Tank El Tight Tank 0 Grease Trap
Other(describe):
ur
4. Effluent Tee Filter present? El Yes EYI"No If yes, was it cleaned? El Yes El No
5. Observed condition of component pu ped.,
All of this estimated
information is non-binding, viali o at..the time mpiq N(�
9 y _T�� on��ble beyond the date above,.
61. System 1111,P,uml,ped By:,, �
00
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewart's Global Environmental, LLC
20 So O i 11 Slj� Bradford, MA 01835
..........
.'W
..................
See above
00,
ign4.reef-Rauler Date
rtW
See above
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc,, 11/12 System Pumping Record Page 1 of 1
Commonwealth of MassachusettsTown of lVorth LAi
Y City/Town of No-Andover � r
System Pumping Record AUG I
Gar ti`
Form 4
G'At SV 9
DEP has provided this form for use by local Boards of Health. other fo-r QQ b t the
information must be sUbstantially the same as that provided here. Before using this EFMLoyi your
local Board of Health to determine the form they use. The System Pumping Record must be subm ted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 (.,MR 15.351.
A. Facility information
Important:When
filling out forms 1. System Location:
on the computer, Ile.
use only the tab fr4 t...-
key to move your Address
cursor-do not
use the return City/Town State Zip code
key.
.0...................
rib . System Owner:
Name
retr�n
Address(if different from location) �
No.Andover _MA
City/Town -- ---- State _ Zip Code
Telephone Number
B. Pumping F�ecord
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑❑ Septic Tank ❑❑ Tight Tank 7>16rease Trap
Other(describe):
4. Effluent Tee Filter present? ❑ Yes I No If yes, was it cleaned? El Yes _1��No
5. Observed condition of component pumped:
)-�kl ellf
.
6. System P4mped By: <
Name Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
24 So_M kAf A
Signature o_ au er _ date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc#1111 2 System Pumping Record e Page 1 of 1