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HomeMy WebLinkAboutSeptember 2025 - Septic Pumping Slip - 351 WILLOW STREET 9/30/2025 ��C�Dl��Cj�����|t� �� K8���������U��f�` ~, = . ~,. Massachusetts =°~~~ �ON/� �f8/~-" '^ *v ��' �f /VU/�) � ��|T�Y / �J��[1 `�/ �~"����°��r ����� �D����.�� ������� '~v System Pumping�� Record D�7 ��� �1 OCT 6 _ `?v�nv J OEP has provided this form for use bv local Boards of Health. Other formsd, but the information must bmeubotonUaUy the same ao that provided here. Before uoing��Mj ��ith your local Board of Health to determine the form they use. The System Pumping Record must bsU the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310CyWR15.351. A. Facility Information Important:When filling out fnmno 1. System Location: on the computer, use only the tab key m move your *uumeu cursor do not No. Andovar MA 01845 use the return key. City/Town S1u1a Zip Code 2. System Owner: Name Addreuo(if different from|ouoUun) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date ofPumping Date 2. Quantity Pumped: Gallons ��--� 3. Component: [l Cesspool n Septic Tank F-1 Tight Tank F-1 Grease Trap MIOther(deacribe): 4. Effluent Tee Filter present? [l Yee Z No If yes, was it cleaned? [l Yea El Nn 5. Observed co ditionf componentpumped: All of this estimated information is non-binding, valid only at the time of_p 8. System Pumped By: Name Vehicle License Number J&S Development Corp. d/b/a Gtewmrt's Septic Service 7. Location where contents were disposed: 8tawerye Global Environmental, LLC See above Signature of HaUbr Date See above Signature of Receiving Facility(or attach facility receipt) Date . —", aY /UQ/�� � ~ d,kq� .�/ ��Cj�������y����|f� C�fK�����������`U����� ��7---'` Commonwealth ' Massachusetts~^~ -~' � >0�c ^ ~"c� ��' rrF ��|T�/ | ����[l ^//'�' System Pumping_,__ _g 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 31OCyNR15.351. d&, Facility Information Important:When filling out forms 1. System Location: on the computer, � use only the tab keYhommmyomr xuueoo cursor-do not No� Andover MA 01845 use the n�um key, City/Town State Zip Code 2. System Owner: Q1,b Name Address(if different from location) City/Town State Zip Code ------------- TelephoneNumbor B. Pumping Record - 1. Date of Pumping Date Quantity Pumped. Gallons 3. Component El Cesspool(s) F-1 Septic Tank F-1 Tight Tank El Grease Trap 0Q Other(describe):r- ` ' 4. Effluent Tee Filter present? [l Yes P No |f yes, was itcleaned? El Yea 0 No 5. Observed condition of component pumped: �s 06 All of this estimated information is non-bindinq, valid only at the time of pumping. Not responsible beyond the date above. . System moma Vehicle License Number J&S Development Corp, d/b/o Stexwerƒs Septic Service 7. Location where contents were disposed: Shawerƒo Global Environmental, LLC 20 Bradford, Signature of Hauler Date See above Signature nf Receiving Facility(or attach facility receipt) Date t5fonn4doo^11/12 System Pumping Record^Page 1 of �m� ` «w�OMYA�. ~/ ^! Commonwealth f Massachusetts ������������\�/f���'u / [�/ ��'fw/� f OCT q. ��|��/ / [J��[l ��/ ~ ' . 1o'c ���s��K� ������~�� ��ec���� System Pumping - - 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 31OCK0R15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab key m move your Address cursor do not No. Andover MA O1845 use the return key. City/Town State Zip Code 2. System Owner: Name Address(if different from location) uqv/mwn State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: 0o 0 Date Gallons 3. Component F-1 Cesspool(s) R Septic Tank [I Tight Tank E] Grease Trap r� Other(describe):�� ` '� 4. Effluent Tee Filter present? [l Yes F\4 No |f yes, was itcleaned? F-1 Yea 0 No G. Observed condition of component pumped: 9 oo�, All of this estimated information is non-bindina, valid only at the time of pumping. Not responsible beyond the date above. 0. System Pumped By: Name Vehicle License Number J&G Development Corp. d/b/o Stevvart'a Septic Service 7. Location where contents were disposed: Gtevvart'a Global Environmental, LLC 20 80. K4i|| St. Bradford, MA 01835 Signature of Hauler Date See above Signatur -o—fReceiving­-F—acility(or attach facility receipt) Date t5fomn4don^ 11/12 System Pumping Record ^Page 1of1 1U-�»� . �Q�� ��8�� ��������C��yV���|fh ��fK8��������������� -'^ w/ /V�y� �Mr� Commonwealth -- '�' " »'�W�0�� �~' ,�� `�v ���t�/ � ��\�/|� ^�/ ~ OCTSystem Pumping Record "� � "����u��� o �����UK��� ' " '2�c � u- �� '^.�� Form 4 DEP has provided this form for use bv local Boards of Health. Other fVmno information must beeubohandaUy the same aa that provided hens. Before using this form''ch�y�vvith 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 31UCPNR15.351. A, Facility Information Important:When filling out forms 1. System Location: nn the computer, DJ�/' c`-�-- ( use only the tab key to move your Address cursor'do not No. Andover MA 01845 use the return City/Townk^y� City/ToStateown S� � Zip Code 2. System Owner: Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: Date at��ons 3. Component F Cesspool(s) F Septic Tank 0 Tight Tank El Grease Trap Other(describe): 4. Effluent Tee Filter present? F Yea rz-Iqo |f yes, was itcleaned? R Yen Fl No 5. Observed condition of component (D L-)061 , All of this estimated information is non-bindinq, valio q�nly at the time of punfe the date above.- 0. SysTte 0 By- V Name nse Number J&S Development Corp. d/b/aSbewart'oSeptic Service 7. Location where contents were disposed: Stevvert's Global Environmental, LLC See above See above -S—igna­tureof—Rece—iving—Fa—cility(or attach facility receipt) Date t5fonn4.doc^ 11/13 System Pumping Record`Page 1of1 Commonwealth Massachusetts �°~- �����l������\8/����/�/ / `�/ /v/����������/ /U�����*� �UVK/ of NL~�� r �`'f^//T- f -' ^ "^w� ^�|��' / �����] Cj/ "~/ ���s���� ���K��^��� �������� OCTSystem Pumping�� Record "^ ' 6 >O>� Form 4 - ^`^~ DEP has provided this form for use by |000| Boards ofHealth. Oth information must be substantially the same ao that provided here. Before using --thief&�N'1'1G}0twith your local Board of Health to determine the form they use. The System Pumping Record must be submitted bo 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: nn the computer, , L use only the tab key to move your Address cursor-do not No Andover MA 01945 uoothoretum � key. u/y//mvn State Zip Code 2. System Owner: Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record Date Gallons 2. Component: F-1 C K El Septic Tank F-1 Tight Tank El Grease Trap Fl Othur(doaoribe): -�- 4. Effluent Tee Filter present? Fl Yaa{�q--No |f yes, was itcleaned? R Yes El No 5. Observed 1-1 67 All of this estimated information is non-loinding, Kalid only at the time_of_pumpjn_g. Not responsible beVond the date above. 8. System Pumped By: —= Name Vehicle License Number J&G Development Corp. d/b/a Stevvart'o Septic Service 7. Location where contents were disposed: Ghovvart'a Global Envirnnmenta|, LLC 2 See above Signature of Hauler Date See above t5funn4.don^ 11/12 System Pumping Record^Page 1of1 Commonwealth of Massachusetts Town ®f'®0 Andover City/Town of No. Andover S 6,2025 o ystem Pumping Record OCT Form 4 2 He( tit DEP has provided this form for use by local Boards of Health. Other forms may be U-PO rk,t-(&ilt 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 No. Andover MA 01845 use the return City/Town State Zip Code key. %011b 2. System Owner: Name Address(if different from location) ............. .............. ---------- City[Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date ..2. Quantity Pumped: Gal. lons 3. Component: ❑ Cesspool(s) F-1 Septic Tank F] Tight Tank El Grease Trap Er, Other(describe): ............. 4. Effluent Tee Filter present? ❑ Yes 0 No If yes, was it cleaned? R Yes Ej No 5. Observed condition of component pumped: All of this estimated information is.non-binding, valid one at the time of pumping. Not responsible beyond the date above. 6, System Pumped By: 3 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. Mill St., Bradford, MA 01835 ---------------- _n See above i '�rinat ure-of Hauler Date ........... See above - Signature of Receiving Facility(or attach facility receipt) Nte­ ­ t5form4.doc- 11/12 System Pumping Record -Page 1 of 1 Commonwealt of Massachusetts Town 0f'V©rtd' An ®Ver City/Town of F System Pumping Record OCT .. 6.2025 Form 4 ea'ti,7 �v t F DEP has provided this form for use by local Boards of Health. Other forms may be usLl�.�t1, /1 information must be substantially the same as that provided here. Before using this form, check wit 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, l ) use only the tab key to move your Address cursor-do not use the return key. City/Town State Zip Code 2. System Owner: "�-1 reb Name - few Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping D e 1 2. Quantity Pumped: �� -- Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank [] Tight Tank 5—Grease Trap Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? El Yes [_J1 No 5. i condition of component pumped: ea v 6�- als� 6. st rrt Pugnped Bn Na a 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 �L\ Commonwealth of Massachusetts City/Town of No. Andover Town C ilk System Pumping Record Form 4 OCT 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, Bef , this form, check with your local Board of Health to determine the form they use. The System Pumlwmiguj'k,"gt,�e submitted to p" the local Board of Health or other approving authority within 14 days from the pum 1rfd%CrrC, 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 key to move your Address cursor-do not No, Andover MA 01845 use the return key, City/Town State Zip Code 1,0116 2. System Owner: Name V (j return Address(if different from location) ---___ ------- ............................. .............. City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 66_ Date - . . Gallo 2. Quantity Pumped: Gallon 3. Component: F-1 Cesspool(s) F1 Septic Tank ❑ Tight Tank [:1 Grease Trap albther(describe): - —---- ...........------------- 4. Effluent Tee Filter present? F-1 Yes M—No If yes, was it cleaned? F] Yes [] No 5. Observed condition of component pumped: C)ch All of this estimated information is non-binding, valid only at the time of pumping. Not responsible beyond the date above. ............... y 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 Global Environmental, LLC 20 So, Mill St., Bradford, MA 01835 See above 7- -2 ez _3 ----------- 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 Town o fNo IL Commonwealth of Massachusetts 4ndover u City/Town of No.Andover OCT System Pumping Record Z�ZS Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used,¢tt#ftlfl information must be substantially the same as that provided here. Before using this form, check wlth 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 Addrpsp cursor-do not �— use the return City/Town State Zip Code key. 2. System Owner: tab d ✓— Name �e SAME Address(if different from location) No.Andover MA City/Town State Zip Code Telephone Number B. Pumping Record e 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 co dition of component pumped: d�_ 6. System Pumped By:_ Name Vehicle License Number Stewart's Septic 58 So Kimball St. , Bradford,MA Company 7. Location where contents were disposed: 20 S . I St.,Bradford,MA Signature Hauler bare Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 /��� mfA�- ~' /VV�A � y������M��O�Me��|+hnfK�����������hL]seft , `'��/KJOyer ���^ ��. C� ,�/� |T�/ U ��yl Dc7 ���s���� ���K��~�K� ������� ' ~��� System Pumping Record �� Form 4 xx �P t��^w� 0 DEP has provided this form for use by local Boards of Health. Other forms may beuood.^�18�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 |ooei Board of Health or other approving authority within 14 days from the pumping date in accordance with 310CN1R15,351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, ' use only the tab key m move your auuveoa cursor-do not No� /\ndnver MA O1845 mm use the ,u key. City/Town State Zip Code 2. System Owner: Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record A 1. Date of Pumping UaEu Quantity Pumped: gal I o n's ................................................ 3. Component: El Cesspool(s) F-1 Septic Tank F-1 Tight Tank dGrease Trap �l Other(describe): 4. Effluent Tee Filter present? r-1 Yes No |f yes, was itcleaned? Fl Yea [�,,,No 5. Observed .� n of component pumped: /r 77 ?`j 1� —Ii> All of this estimated �s rt,6n-bindN_, valid only at the time of pumpin_g. Not r"s onsible beyond the date above. 6. System d Name Vehicle License Number J&S Development Corp. d/b/a Gbamart'e Septic Service 7. Location where contents were disposed: Gtevvad'e Global Environmenta|, LLC See above Date See above Signature of Receiving Facility(or attach facility receipt) Date t5honn4dnc-11/12 System Pumping Record^Page 1of1 �.� /��� ��N^�� ��C�������OVVe��|fh ��f K�������2�[:�`Us��f+s �' ««VD�And�-k.��r ' ��'+`//7- f � ���� ��� ��/ / / No. Andover System Pumping RecordOCT �'2025 Form 4 DEP has provided this form for use by local Boards of Health. Other forms may beU"-S'6*d,-16d4t lh�0 information must ba 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 dabs in accordance with 310CyVIR 15.351. 6b, Facility Information Important:When filling out forms 1. System Location: nn the computer, use only the tab ' key to move your Address cursor-do not No� Andover MA 01845 use the ngvm key. City/Town State Zip Code 2. System Owner: Name Address(if different from location) City/Town State Zip Code Telephone Number B. ���00�~�� Record Pumping 1 Date of 2 Quantity Pumped: - � oa�o � � Gallons 3. Component: El Cesspool(s) F-1 Septic Tank F-1 Tight Tank [3��BreasoTnap Other(describe): 4. Effluent Tee Filter present? R Yee No If yes, was it cleaned? R Yea No 5. Observed condition ofcomponentpumped: All of this estimated nxu////uuu// 65/hon-binding, V'alid only at the time of pumping. Not responsible beyond the date above. G. System // ' /7 1�` / z� �--� U L~_8� ° ^/L~- {_~/ ~�^/ Name Vehicle License Number J&S Development Corp. d/b/a Gtuvvart'eSeptic Service 7. Location where contents were disposed: Stewa�rtl's GI See above See above Signature of Receiving Facility(or attach facility receipt) Date moorm4duc^ 11/12 System Pumping Record^Page 1of1 r� Commonwealth f Massachusetts '"/j 8�^�^ ������Ol��|�\�/����/u / [�/ xv/��������[�/ /U�������� "/ ^«��&G /q ''^��/, ` r�' of ~w�Nqr ��|I�/ � C�\8/[l ^+/ ~" System Pumping Record r OCT 6 �� �vcJ Form 4 DEP has provided this form for use by local Boards of Health. Other information must be substantially the same oothat provided here. Before using this form, 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 31OCPNR15.351. 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 ndum � hey. City/Town State Zip Code 2. System Owner: t ow 1, Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record -70, b5- I. Date of Pumping 2, Quantity Pumped: Date Gallons 3. Component: F-1 Cesspool(s) F-1 Septic Tank 0 Tight Tank El Grease Trap U2[ Other(deeoribe): - 4 ` 4. Effluent Tee Filter present? F-1 Yes El No If yes, was it cleaned? F-1 Yes El No 5. Observed copdition of componentpumped: All of this estimated information is non-bindinq, valid only at the time of pumping, e d the date above. G. System Pumped B Name Vehicle License Number J&8 Development Corp. d/b/e 8tewart'oSoptio Service 7. Location where contents were disposed: Gtevvart'aG|oba| Environmonta|, LLC See above Signature of Hauler Date See above Signatune­of ReceiviiWg Facility(or attach facility receipt) Date---- 0fonn4duc^ 11/12 System Pumping Record ~Page 1 of ��� »W�Y/ (}fk/��^ �D��k�� Commonwealth fK8 Massachusetts�����l����|�\�q���/u / ��/ .v/��������C�/ 'U�����*� ��'+`�/�~������ [�f OCT � y02� - _- ���s��K� ������^�� �������� System Pumping�� Record ' — ������, Form ^ « '�� /' po-P�b-tm7ent OEP 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 local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board ofHealth or other approving authority within 14 days from the pumping date in accordance with 31OCMR15,351. A, Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab �^ ' kayk`move your Address cursor-do not No� Andmver MA 01845 use the emm hey, City/Town State Zip Code 2. System Owner: �I Umb JOY Name - Address(if different from location) Qtyl-rown State Zip Code Telephone Number B. Pumping Record 1. Date ofPumping Date2. Quantity Pumped: Gallons 3. Component: [l Cesspool(s) El Septic Tank F-1 Tight Tank El Grease Trap Other(describe): 4. Effluent Tee Filter present? El Yes [Z No |f yes, was itcleaned? 0 Yee El No 5. Observed condition of component pumped: 9 CIO 3 All of this estimated information is non-bindinq, valid only at the time of pumping ible _,_Not_re_sons beyond the date above. O. System Pumped By: Name Vehicle License Number J&G Development Corp. d/b/o Stovvaryo Septic Service 7. Location where contents were disposed: 8bavvart'a Global Environmental, LLC 20 So Mill St Bradford MA01835 Signature of Hauler Date See above Signature of Receiving Facility(or attach facility receipt) Date t5fonn4.doc^1 Ill 2 System Pumping Record^Page 1of1 Commonwealth of Massachusetts City/Town of No. Andover System Pumping Record oc� Form 4 DEP has provided this form for use by local Boards of Health. Other forms maybe used ut,vthe information must be substantially the same as that provided here. Before using this form, ffk'Jw h your local Board of Health to determine the form they use. The System Pumping Record must be subhiift6dto 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 5- V ff� key to move your Address cursor-do not No. Andover MA 01845 use the return key, City/Town State Zip Code 2. System Owner: reb Name ietwn ..................... ------------ Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record C�o 0 1. Date of Pumping Date 2. Quantity Pumped: G il/lo n s 3. Component: El Cesspool(s) El Septic Tank F-1 Tight Tank El Grease Trap Other(describe): 4. Effluent Tee Filter present? E:1 Yes [2 No If yes, was it cleaned? Ej Yes E] No 5. Observed condition of component pumped: 9C)o All of this estimated information isnon- valid only at the time of pumping. Not re.....binding, responsible beyond the date above. 6. System Pumped By: 0 --------------- 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. Mill St., Bradford, MA 01835 See above Z7 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 City/Town of No. Andover System Pumping Record ot, Form 4 OCT DEP has provided this form for use by local Boards of Health. Other for'rns maybe used, but the information must be substantially the same as that provided here. Before usihg'fhis�,f-,qrm check with your submitted to, local Board of Health to determine the form they use. The System Pumping Record ; 'J* 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 they mputer, use onthe tab ...... 6(v G d --S, key to move your Address cursor-do not No. Andover MA 01845 use the return .....--------- key. City/Town State Zip Code 2. System Owner: J111 Name renrn ............... ------ Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record Date 0 ,9 ons ,0 Gall 1. Date of Pumping I ), — 2. Quantity Pumped: 3. Component: El Cesspool(s ❑F-1 Septic Tank Fj Tight Tank El Grease Trap 3'16ther(describe): .❑ ..... 4. Effluent Tee Filter present? E] Yes E3 No If yes, was it cleaned? R Yes E] No servedrondition 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 By: 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 MillBradford, MA 01835 ............... See above ............. Sig�n'a—ture 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