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Home My WebLink AboutOctober 2025 - Septic Pumping Slip - 351 WILLOW STREET 10/31/2025 Commonwealth ��C�D]��C��]\8/G��/v / `�/ ��~— If -- �U�� f�� = ��'t^^/�-�� f ~" '»u/u/��MwW��p System Pumping Record ^�� n �� nu��n xu � n- �� NOVorm 4 ',° ` 10 /0y5 DEp has provided this form for use by local Boards uf Health. Otherpy p used, but the information must be substantially the same as that provided here. BEfd/- r�Mg�We th your local Board of Health to determine the form they use. The System Pumping Record rnuet-h{�Witted to the |oou| Board of Health or other approving authority within 14 days from the pumping date in accordance with 310C;WR 15.351. A, Facility Information Important:When fillingout 1� System ` - 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. 2. System Owner ---------------------- .................ill— Name Addrenn(if different from location) City/Town State Zip Code Te|aphoneNumbar B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: Date Gallons 3. Component: F-1 Cesspool(s) El Septic Tank R Tight Tank R Grease Trap L�� Other(describe). -- 4. Effluent Tee Filter present? R Yes [a.No |f yes, was itcleaned? El Yee E] No 5. Observed c nditionf componentpumped: C_�? All of this estimated information is non-binding, vali I or��tt�he time f in2. Not responsible beyond the date above. 6. System Pumped By: Name Vehicle License Number J&G Development Corp. d/b/a 8(avved'o Septic Service 7. Location where contents were disposed: Stevvart'e Global Environmnntm|, LL(| Bradford, See above /6/- Signature of Hauler Date See above Signature of Receiving Facility(or attach facility receipt) Dote t5mnn4.dno^11/12 System Pumping Record`Page 1of1 Commonwealth �, ��0OD��yl\A/��/�' / ��/ Massachusetts ��'fw/�~ f ��|��' , ��Vy1 ��/ No. Andover System Pumping Record Form 4 DEP has provided this hznn 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 Vf 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 31UCIVIN15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, ��/ use only the tab /// key mmove your Address cursor-do not No. Andover MA 01845 use the return key. City/Town State Zip Code 2. System Owner: Name Address(if different from location) utyl/own State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2� C}u�ntUx Pumped: Date ` ' � Gallons 3. Component: [| Cesspool(s) El Septic Tank El Tight Tank F-1 Grease Trap aO�ar(deoohbe): 4. Effluent Tee Filter present? 0 Yes/B~|No |f yes, was itcleaned? Fl Yes F-1 No 5. Observed con ition of component pumped: All of this estimated information isnon-binding,valid only at the time of pumping. Not responsible beVond the date above. O. System Pumped By: ' - /�� - aelk ~��1� Name Vehicle License Number J&S Development Corp. d/b/a Gtevvart'a Septic Service 7. Location where contents were disposed: St*vvert'a Global Envinonmenta|, LLC 20 So, Mill St Bradford, 5 See above Signature of Hauler Date See above Signature of Receiving Facility(or attach facility receipt) Date t5fonn4doc~ 11/12 System Pumping Record ^Page 1of1 Commonwealth � ��l�l��[l\8/��/u / ��/ Massachusetts ��'f*/T- � ��|��/ / C��[l C]/ No. Andover System Pumping Record ��*�� n ��U�K� m��u � 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 dote in accordance with 31OCKAR15,3G1. 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 G1aVa Zip Code 2. System Owner: %,Go 1 Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record' ��. � �00��U�� 1 Date 2 Quantity� ode � � Gallons 3. Component: [l Cesspool(s) [l Septic Fl Tight Tank El Grease Trap Z Othmrkbaaorbe>- 4. Effluent Tee Filter present? � Yes � No If yes, was it cleaned? � Yes 0 No — ----'-- -- ition of component pumped: Uofthiseotimehed information is non bindin valid only atth time f pumping. Not responsible beyond the date above. _ System_ � ^ ~/ &/,�.................................. Name Vehicle License Number Service 7. Location where contents were disposed: Gtewa/ƒa Global Environmental, LLC 20 Go yWiU 8t. Bradford, MA 01835 See above Signature ufHauler Dote See above Signature o[Receiving Facility(or attach facility receipt) Date t5fonn4.don^ 11/12 System Pumping Record^Page 1of1 Commonwealth � ��C��7�]��[l\��/u / `^/ /vx��/ /Usetts �`'f`//T- f ��|��/ / C��[1 ��/ No. Andover ��s�� K��~�� 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 fnnn' check with your local Board cf Health bn 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 date in accordance with 310CK4R 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, �^�) /,6A� use only the tab -/� ' v,' //ob'd Jy key to move your Address cursor-do not No. Andover MA 01845 mm City/Townuoe�he �u koy� City/TownState Zip Code t 01,6 2. System {}vvnur Name AdUreao(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2 Quantity Pumped: oo�� Gallons 3. C R Cesspool(s) El Septic Tank R Tight Tank El Grease Trap 21-6ther(deocribe): 4. Effluent Tee Filter present? Fl Yes ET No |f yes, was itcleaned? F-1 Yea F-1 No 5. Observed ditionof component pumped: 6'ey All of this estimated information is non-bindin valid only at the time ofu_mpjng. Not re e date above. G. System Pumped B Name Vehicle License Number J&S Development Corp. d/b/a Stevvart'e Septic Service 7. Location where contents were disposed: Gtewart'e Global Environmenta|, LLC 20S Mill St., Bradford Signature of Hauler Date See above Signature of Receiving Facility(or attach facility receipt) Date t5fonn4,duc^ 11/12 System Pumping Record`Page 1of1 Commonwealth of Massachusetts City/Town of No.Andover System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, f ❑ use only the tab key to move your Address cursor-do not use the return City/Town State Zip Code key. 2. System Owner: Name /ems SAME 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. Compon ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): ` � �' �� C — 4. Effluent Tee Filter present? ❑ Yes /�] No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: �5 6. System Pumped By: / `;l ❑- ame Vehicle License Number Stewart's Septic 58 So Kimball St. , Bradford,MA Company 7. Location where contents were disposed: 20 So. ill St.,Bradford,MA Signature of Haulef Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 Commonwealth � Massachusetts ��[��[l\&K��/u / (�/ ��'f�//��, f | VV� �� / / `� / No. Andover J. 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 ho determine the form they use. The Gyohsm 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 31OCN1R15.351. | A, Facility Information | Important:When � filling out forms 1. System Location: � vw the computer, use only the tab key m move your Address cursor'do not No. Andover MA 01845 use the return hey. City/Town State Zip Code .' 2. System Owner: / memo / / / ------- Addmmo(if different from location) odylTvwn State Zip Code Telephone Number ' B. Pumping Record 1. Date ofPumping 2 Quantity — oma � � GoUuno 3. Component: El [l Septic Tank El Tight Tank El Grease Trap ]thar(describe): — 4. Effluent Tee Filter present? F� Yes J2� No |f yes, was itcleaned? 0 Yea E] No 5. Observed c nditionofcomponentpumped: 01$A 17 All of this estimated information is non-bindinci, valid only at the time ofpumpinq. t res onsible beyond the date above. 6. System Pumped B Name Vehicle License Number � J&S Development Corp. d/b/o 8tevvmd'a Septic Service 7. Location where contents were disposed: Stowort'oG|obo| Environmental, LLC 20 So. Mill St., Bradford, MA 01835 See above Signature of Hauler Date See above Signature m Receiving Facility(or attach facility receipt) Dote 0fonn4.dnc~ 11/12 System Pumping Record^Page 1 of Commonwealth �� Massachusetts ^�CjF��/u / w/ ��'f^//l� f ��|�y' ^ ��M C]/ No. Andover System ��K��~�� —^ — -- Pumping Record ' — Form 4 0EP 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 hero. 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 doby in accordance with 31OCMR153G1. A. Facility Information Important:When filling out forms 1. System Location: nn the computer, usennlyUmtab key oo move your *uureou ' cursor do not No. Andover MA O1O45 mm use the tu key. City/Town State Zip Code 2. System Owner: Name Agdmoo(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 16 |J r D �� 1. Da�� ofPumping 2. Quantity Pumped: 3. Component 7 Cesspool(s) El Septic Tank El Tight Tank El Grease Trap y Other(describe): 4. Effluent Tee Filter present? F1 Yee No If yes, was it cleaned? F� Yea Fl No 5. Observed condition of component pumped: �06�, All of this estimated information is non-binding, valid only at the time of pumpking. Not responsible beyond the date above. 0. System Pumped By: Name Vehicle License Number J&G Development Corp. d/b/e Gtevvort'o Septic Service 7. Location where contents were disposed: Stovvert'o Global Environmenta|, LLC 20 So Mill St , Bradford See above Signature of Hauler Date See above Signature of Receiving Facility(or attach facility receipt) Date 15fonn4.dno' 11/13 System Pumping Record^Page 1u(1 Commonwealth ��[�Dl��C][l\&��/w / ��/ ��'+u/�- f ��|��/ n ��[] ��/ No. Andover System Pumping Record ��u�� n ��8�� o��n � � n- �� Form 4 DEP has provided this form for use by |uoa| 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 8yeham Pumping Record must be submitted to the |oou| Bound of Health or other approving authority within 14 days from the pumping date in accordance with 31OCKAR 15.351. A, Facility Information Important:When filling out forms 1. System Location: on the computer, 4 n� use only the tab key Vn move your Address cursor-do not No. Andover MA 01845 use the/atum key. City/Town State Zip Code %UMb 2. System Owner: Y 7- Name Addmaa(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record / 1. Da�� ofPumping Date Gallo �� Quantity Pumped: Sa|lono 3. Component: El Cesspool(s) Ej Septic Tank El Tight Tank El Grease Trap E]`Other(deacribe): 4. Effluent Tee Filter present? F-1 Y*o El~No If yes, was it cleaned? F-1 Yes F-1 No 5. Observed 99ndition of componentpumped: U of this ueUmetad information is non-binding, valid only at[h d f i Not respo siblebeyond the date above. O. System Pumped By: Name Vehicle License Number J&S Development Corp. d/b/a Gb*vvert'o Septic 8emims 7. Location where contents were disposed: Stovvart'a Global Environmental, LLC 20 Bradford, Signature of Hauler Date See above Signature or Receiving Facility(or attach facility receipt) Date t5fonn4doc- 11/12 System Pumping Record`Page 1 of Commonwealth �� Massachusetts ��l��[]\8/�)��/u / ^^/ ��'f`�/�' f | �� / " / No. Andover System Pumping �� v� =�y�u�� x^��m �� Form 4 OEP has provided this form for use by local Boards ofHealth. 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 br 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 310CN1R 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab tA)/ key to move your Address cursor-do not No. Andover MA 01845 use the return koy. City/Town State Zip Code 2. System Owner: /7 Name Address(if different from location) City/Town Gtuha Zip Code Telephone Number B. Pumping Record 1. Dab* of Pumping 2Date � Quantity Pumped: Gallons 3. Component: El Cesspool(s) F1 Septic Tank El Tight Tank El Grease Trap �H Other (describe): 4. Effluent Tee Filter present? [l Yes No If yes, was it cleaned? Fj Yea E] No 5. Observed 6,)l(I All of this estimated information is non-binding,valid only at the time of_pym Ing. Not onsib date above. O. System Pumped S te P d By: Name Vehicle License Number J&G Development Corp. d/b/o 8bewerfe Septic 8en/ioe 7. Location where contents were disposed: � Sbawort'sG|obo| Environmental, LLC U So. Mill St., Bradford, MA 01835 See above Signature of Hauler Date See above Commonwealth of Massachusetts City/Town of No. Andover __ ❑ System Pumping Record „Ai }vOJr Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, / use only the tab I � ��.l_o �_ YJ _ key to move your Address cursor-do not No. Andover MA 01845 use the return - - — --- — -- key. City/Town State Zip Code 2. System Owner: r ,eb r Name ienxn --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. Compo ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): = ------ -- ------ 4. Effluent Tee Filter present? ❑ Yes ❑Nor If yes, was it cleaned? ❑ Yes ❑ No 5. Observed c ition 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 Bye., 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 . Mill St Bradford, MA 01835 _ ... 74. --- -- See above ,C'C'�' /`�c . Signature of Haul r Date See above Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1 `�'N Commonwealth of Massachusetts f City/Town of No.Andover a System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab ❑ ��(_, � / '� key to move your Ad re cursor-do not �/r❑ .� use the return key. ` City/Town State Zip Code 2. System Owner: \✓-- `/(/ '"0% Name tenor SAME _ Address(if different from location) No.Andover MA City/Town State Zip Code Telephone Number B. Pumping Record > 1. Date of Pumping /d G p 2. QuantityPumped: DateGallons 3. Compone ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other 7 (describe): 4. Effluent Tee Filter present? ❑ Yes�e If yes, was it cleaned? ❑ Yes ❑ No 5. Observed co dition of component pumped: �S--44=� 6. System Pumped B Name Vehicle Number Stewart's Septic 58 So Kimball St. , Bradford,MA Company 7. Location where contents were disposed: 20 So. II St"Bradford,MA Signature of Haule Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts 'roNn ()f NICV)Andover City/Town of No. Andover Nov 10 2025 System Pumping Record Form 4 311101 D(-,)Part DEP has provided this form for use by local Boards of Health. Other forms may be u59,191 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 CMR 15.351. A. Facility Information Important:When rf 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. 2. System Owner: tabv .......................----------- Name return ------------------------------...... ----------------------- Address(if different from location) ........... City/Town State Zip Code Telephone Number B. Pumping Record ( ) 2. Quantity Pumped 1. Date of Pumping Date j Gallons 3. Componen ❑ Cesspool(s) M Septic Tank R Tight Tank El Grease Trap Other(describe): escribe): V AV ............... 4. Effluent Tee Filter present? R Yes E0 No If yes, was it cleaned? R Yes R No 5. Observed condition of component pumped: All of this estimated information is non-bininq_,_vald only nl at the time of p_ym in . 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. Mill St., Bradford, MA 01835 e abo�v ;! �c�21Z 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 f Massachusetts ��FD��yl\8��'��/u / C�/ m/��1��/ /UsetTs ��'f�//T~ f ��|��/ , C]��yl ��/ No. Andover System Pumping Record Form 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 an that provided here, Before using this fonn, check with your local Board of Health to determine the h>/m 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 31OCN1H15.351. A. Facility Information | Important:When ! filling out forms 1. System Location: on the computer, use on��e�b -/ / ' � to� �� Address oumn � � do not No. Andover MA 01845 uoe�e��m key. City/Town State Zip Code %Q1,b 2. Gynbam Owner: Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record — cx 1. Date of Pumping Date � 2. Quantity Pumped- GoUnno 3. Component F-1 Cesspool(s) F1 Septic Tank F-1 Tight Tank El Grease Trap (2L Other(describe): -- 4. Effluent Tee Filter present? F� YeeJR No |f yes, was itcleaned? F1 Yen [:1 No 5. Obsemed diti f tpumped: All of this estimated information is non-binding, valid only at the timie e��. Not responsible beyond the date above. G. System Pumped By: Name Vehicle License Number J&S Development Corp. d/b/a 8tewart'o Septic Service 7. Location where contents were disposed: Shsvvert'o Global Envinonmenta|, LLC 20 Go. K8i|| St., Bradford, MA 01835 See above—ZO�-�Py� Signature of Haul6r Date See above Signature of Receiving Facility(or attach facility receipt) Date t5form4.Uon^ 11/12 System Pumping Record`Page 1of1 Commonwealth of Massachusetts City/Town of No.Andover System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: _ on the computer, S w I^ ( l U vy use only the tab _ key to move your Addr ss cursor-do not 't t / P ❑� }�- use the return City/To State ! key. Zip Code VQ 2. System Owner: Name enrm Address(if different from location) No.Andover MA _ City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. QuantityPumped: l ' O� Date p Gallons 3. Component: ❑ Cesspool(s) << ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): J t y A J 4. Effluent Tee Filter present? ❑ Yes ❑No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 6. System Pumped By: 1A,CA❑Y� _ 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 Andover 1 \- Commonwealth of Massachusetts 1 City/Town of No. Andover No v 0 2025 System Pumping Record _❑o Form 4 �Opailtllent 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 No. Andover MA 01845 use the return --------- key. City/Town State Zip Code 2. System Owner: ----------------------❑ Name etwn Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping -k' 5 2. Quantity Pumped: � 00 Date llons 3. Component: ❑ Cesspool(s) El Septic Tank F-1 Tight Tank 0 Grease Trap [4 Other(describe): , I U c Cj-(- ----..................- 4. Effluent Tee Filter present? (❑Yes Fj No If yes, was it cleaned? ❑ Yes E] No 5. Observed condition of component pumped: 9 vo A All of this estimated information is non-binding, valid only at thetime of pqjpRog. Not responsible beyond the date above. 6. System Pumped By: 0 Y) ...........................— 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 $o. Mill 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 Commonwealth Massachusetts ��lO0��[]\8/��/u / ^^/ /v/��/ /U��`.u.� ��'+w/T' f ��|`�' x ��V�� / No. Andover System Pumping Record ��u�� u �K�K�U�� u^��" � Form 4 DEP has provided this form for use by |000| 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 |000| Board of Health or other approving authority within 14 days from the pumping date in accordance with 31UCIVIR15.351. A, Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab / ^ ' key 0omove you/ xuueoo cursor'do not No� Andovor MA 01845 mm use the tu key. Cityl-rmwn State Zip Code 2. System Ow Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 6 ~\ , 1. Date of Pumping Date Quantity Pumped� 8o||on» 3. Component |l Cesspool(s) El Septic Tank F Tight Tank El Grease Trap EKOther(deaoribe): -- 4. Effluent Tee Filter present? [] Yea No If yes, was it cleaned? El Yes Fl No 5. Observed nditionmf component pumped: All of this estimated information is non-bindinci, valid only at the time of pumping. Not responsible beyond the date above. G. System Pumped B Name Vehicle License Number J&S Development Corp. d/b/a Gtevvart'e Septic Service 7. Location where contents were disposed: Gtewart'o Global Environmental, LLC 20 So. K8i|| Si Bradford, MA 01835 Signature of Hauler Date See above Signature of Receiving Facility(or attach facility mon|pV ootn t5fonn4duo^ 11/12 System Pumping Record^Page 1uf1 Commonwealth Massachusetts | ��]��[l\�/�>��/u / `�/ /v/��[�/ /U��^.� ��'f^//�' f ��|��, ^ ��] ��/ No. Andover ��s�� K��~�� System Pumping�� Record -- For00 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 31OCK4R 15.351. dk, Facility Information Important:When filling outfn 1. System Location: on the computer, z c | use only the tab | key to move your Address cursor'do not No. Andover MA 01845 | uoethongum \ key. Qty[Tonn State Zip Code | 2. System Own Name Address(if different from location) CityfTown State Zip Code Telephone Number B. Pumping Record Date Gallons 3. Component F-1 Cesspool(s) Septic Tank Tight Tank Grease Trap ��'O�ther(describe): 4. Effluent Tee Filter present? F Yes&Q No |f yes, was itcleaned? F Yes El No 5. Observed ition of component pumped: 2 All of this estimated information is non-bLi nding, valid only at the time of purn Not�resonsb��above. 8. 8yabam Pumped By: Name Vehicle License Number J&G Development Corp. d/b/o Gbevvort's Septic Service 7. Location where contents were disposed: 8bavvert'a Global Environmental, LLC 20S Mill S B d See above�e Signature of Hauler Date See above