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Home My WebLink AboutNovember 2025 - Septic Pumping Slip - 351 WILLOW STREET 11/28/2025 . Ibi ' P�Ortl�l Andover Commonwealth of Massachusetts 'V11 O'f C City/Town of No. Andover DE 2025 System Pumping Record He Form 4 "`J� §,-OPail men t 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 0 --.-.-.-._- key to move your Address cursor-do not No. Andover MA 01845 use the return key. City/Town State Zip Code Z 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- Gallons/See --------------------- 3. Component: F-1 Cesspool(s) El Septic Tank El Tight Tank [:1 Grease Trap ❑_Other(describe): ke -_ 4. Effluent Tee Filter present? M Yes M.No If yes, was it cleaned? Ej Yes 0 No 5. Observed gondition 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. Mill St., Bradford A01835 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 of Massachusetts Andover City/Town of No.Andover DC ® � 2025 — System Pumping Record Form 4 li.'L;11tih Lr)oparfi �a DEP has provided this form for use by local Boards of Health. Other forms may be used, butt 9pt 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 �_Y �r�/�UJ key to move your Add re s cursor-do not ❑�i��i�� use the return City/Town State Zip Code key. 2. System Owner: reb Name eAm! 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. Compone t:. ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe):v°4-�"z'^ 4. Effluent Tee Filter present? ❑ Yes gNo If yes, was it cleaned? ❑ Yes (❑ No 5. Observed condition of component pumped: ❑ w 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 So. ill St.,Bradfor ,MA C Signature of Hauler _ Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 �� VV/� �]�� O�^VA� Commonwealth fK�Massachusetts - --`�, ��C��]��[l\&q��/u / ��T m/��/ /[j��6�TT� (�'fo/T'��8�[l ��f DEC �07� - ^~�u ��s�� Pumping Record System - r- �� ' --- ' — Form 4 uI kDepartMent 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 b) determine the form they use. The 8yebsm Pumping Record must be submitted b) the local Board of Health or other approving authority within 14 days from the pumping doha in accordance with 31OCK8R15.351. J&, Facility Information Important:When filling out forms 1. System Location: on the computer, 2 use only the tab / / ' key 0o move your auumoo cursor-do not No. Andover MA 01845 use the return City/Townkey� City/Town State Zip Code 2. System Owner: ------- Address(if different from location) QtylTnwn State Zip Code To|ophonaNumbor B. Pumping Record 1. Date ofPumping Date ' �� C)uanUh/ Pumpod� Gallons 3. Component [l Cesspool(s) Septic Tank Tight Ta k F Grease Trap SZ Other(describe): 4. Effluent Tee Filter present? [l Yes �j No If yes, was it cleaned? 0 Yes Ej No 5. Observed condition of component pumped: information is non-binding, valid only at the�time of_pumpin)_,_Nqtresponib��. 8. System Pumped By: Name Vehicle License Number AS Development Corp. d/b/a Stewvart'a Septic Service 7. Location where contents were disposed: Ghavvert'e Global Environmenta|, LLC 20 So. Mill St., Bradford, MA 01835 See above Signature of Hauler Date See above GignommnfRoueivingFaoi|i�y(ura1toohfaoi|itymcoipt) Date �m� ^fN^�� 8� U`�mJ</ m /no/u/�U| Commonwealth ' ��K]O��C]O\&��/u / ^^/ � ��'f`//T- f ��|��/ / ��V[l C�/ D�[ — � >0��__~ ^ �.�^ System Pumping �� | �� xx��u ^� Form 4 Department DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must ba substantially the same aethat provided here. Before using this form, check with your |ouo| Board of Health bn determine the form they use. The 5ynbam Pumping Record must be submitted to the |nom| Board of Health or other approving authority within 14 days from the pumping date in accordance with 310CIVIR 15.351, A, Facility Information Important:When filling out forms 1. System Location: on the computer, � use un�the tab key 0o move your *uueon cursor do not No. Andover MA 01845 use the return key. CityrTmwn G1e1a Zip Code to" 2 System � /7 Name Address(if different from location) CitwTmwn Stuto- Zip Code Telephone Number B. Pumping Record 1 � 1. Date of Pumping Date2. Quantity Pumped: Gallons ' 3. Component D Cesspool(s) R Septic Tank F Tight Tank F Grease Trap P Other(describe): 4. Effluent Tee Filter present? [l Yes [)� No If yes, was it cleaned? E] Yes El No 5. Observed condition nf component pumped: Soo All of this estimated information is no"- inding, valid only at the time of pumping. Not responsible beyond the date above. O. System Pumped By: Name Vehicle License Number J&S Development Corp. d/b/o Gtevvod's Septic Service 7. Location where contents were disposed: Stewart'a Global Environmental, LLC 20 Go Mill St. Bradford MA 01835 See above Signature of Hauler Date See above Signature of Receiving Facility(or attach facility receipt) Date t5fonn4.Uoc-11/12 System Pumping Record^Page 1of1 �� Commonwealth /�� r�k � ^^C��D\8/6��m / `�/ ^," w/ North Andover ,��'| �� f �� 7 | �� ^�/ No. Andover � ��yste�� u��p^ng Record �� ?8?� Form 4 ��c , o N �� r� DEP has provided this form for use by local Boards of Health. [}tharforms may�6'u�� information must be substantially the same as that provided here. Before using this form, check with your local Board of Health tndetermine the form they use. The System Pumping Record must bo submitted tu the |ooe| Board of Health or other approving authority within 14 days from the pumping date in accordance with 310C[NR 15.351. A. Facility Information Important:When filling �*o 1 System� ' �� _on the computer, / y }J ^' mm��e1� key to move your Address cursor'do not No. Andover MA 01845 use the return key. City/TowStatemwn � Zip Code _ System Owner: Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record /( ~ / (^ >) 1. Date ofPumping Date 2. Quantity Pumped: Gallons 3. C pone Fl Cesspool(s) Septic Tank F-1 Tight Tank F� Grease Trap Other(d000ribu): . 4. Effluent Tee Filter present? F-1 YeeRL-No |f yes, was itcleaned? [l Yes E] No 5. Observed condition of componentpumped: 6�d k All of this estimated information is non-binding, valid onIV at the time of pumpLin Not responsible beyond the date above. 6. System Pumped B Name Vehicle License Number J&S Development Corp. d/b/a Shswed'o Septic Service 7. Location where contents were disposed: GtevvorCo Global Environmental, LLC 20 So. MAI St., Bradford MA 01835 _7 See above Signature of Hauler Date See above Signature of Receiving Facility(or attach facility receipt) Date mfonn4.Uuc- 11/12 System Pumping Record`Page 1of1 Commonwealth of Massachusetts ®�� ®rt Andover City/Town of No.Andover System Pumping Record DEC2025 Form 4 �P R S DEP has provided this form for use by local Boards of Health. Other `riiis'in.V _qgh' � information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab key to move your Address cursor-do not use the return City/Town State Zip Code key. 2. System Owner: A-j /��' Name ieNm Address(if different from location) No.Andover MA _ City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Dl� � 2. Quantity Pumped: Gallons 3. Compone ElCesspool(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: ( ry W- 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 So. ill St.,Bradford,MA _._.- � - Signature of Haul r Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 /LvVy� o� �� 8M�^�� ~ |+�� r�' %� �� +� -' ' °'�y.� `��[��C]�V��m / m m/��/ /U�� ` /^^�� r~' \�[1 r�� ' T�/ � � No. AndoverDEC - � 20y� System Pumping Record - ~�o System Form 4 �� "�&� Depart � DEP has provided this form for use bv local Boards of Health. Other forms may be used, butt��^^ information must ba substantially the same as that provided here. Before using this form, check with your local Board of Health bo determine the form they use. The System Pumping Record must be submitted to the |oou\ Board of Health or other approving authority within 14 days from the pumping date in accordance with 31OCPWR 15.351. A~ Facility Information Important:When filling out forms 1. System Location: on the computer, U�} use only the tab ~ key to move your Address cursor'do not No. Andover MA 01845 use the return hey. City/Town State Zip Code 2. System Owner: Name AdUmeu(if different from location) City/Town G1ehe Zip Code Telephone Number B. Pumping Record - 1, Uabm of Pumping Date Quantity Pumped: GoUnno 3. Component: [l Cesspool(s) R Tight Tank F-1 Grease Trap Other(describe): -- 4. Effluent Tee Filter present? Fl Yes 0 No If yes, was it cleaned? Ej Yes F] No 5. Observed ndition of componentpumped: All of this estimated information is non-binding, valid only at the time of ump�n_g. Not responsible beyond the date above. 0. System Pumped Name Vehicle License Number J&S Development Corp. d/b/a GbewarƒeGeptio Son/ice 7. Location where contents were disposed: Stewert'e Global Environmental, LLC 20 Bradford, 10� See above Signature of Hauler Date See above Signature of Receiving Facility(or attach facility receipt) Deoo t5fonn4.doc- 11/12 System Pumping Record^Page 1of1 Commonwealth of Massachusetts T-Tvn C'f K10rib AndOVer City/Town of No. Andover System Pumping Record DEC - 12025 Form 4 DEP has provided this form for use by local Boards of Health. Other fol.04--�;;Bet- information must be substantially the same as that provided here. Before using this t03"i 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 �v? s key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. 2. System Owner: Name . ...................................................... r5eLIC-Le AV----- 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: F-1 Cesspool(s) F-1 Septic Tank El Tight Tank El Grease Trap 41 5-Z2 in�L'61 Z C/,"Other(describe): 4. Effluent Tee Filter present? 0 Yes QgLNo If yes, was it cleaned? F-1 Yes ❑ No 5. Observed dition of component pumped: tl X7 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. 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 � K�Massachusetts - -`' O' /nwYU/��M�� ]��][l\8/��/u / C�T m/��/ /UGK�I�� ''�°`°` K�\8/[l C�T w f �� ` �/ ^ DEC � � System PumpingRecordRecord —�^ ^ 2025 System F��ON � � �U�� DEP has provided this form for use by local Boards of Health. Other forms maybeUo�I~b��r�^ i 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 14dmys from the pumping date in accordance with 31OCMR15.351. A. Facility Information 'mportant:When killing out forms 1. System Location: �n the computer, (ey to move your Address ' No. Andover MA 01845 City/Town State Zip Code 2. System Owner: ----- Name / � | xoomvs(if different from location) � | City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component F-1 Cesspool(s) El Septic Tank El Tight Tank [l Grease Trap 0ther(deeorib*): 4. Effluent Tee Filter present? F� Yee �d_Wo |f yes, was itcleaned? R Yoe El No b. Observed o diU f tpumped: All of this estimated information is non-binding,valid only at the tine of umping. Not responsible beyond the date above. S. System Pumped By: Name Vehicle License Number J&S Development Corp. d/b/e 8tewart'eSeptio Service 7. Location where contents were disposed: Stevvart'e Global Environmental, LLC 20 SBradford, Signature of Hauler Date See above Signature of Receiving Facility(or attach facility receipt) Date t5fonn4duu^ 11/12 System Pumping Record^Page 1 of &'\ Commonwealth of Massachusetts Town of Nod Andover = r City/Town of No.Andover System Pumping Record DEC - 12025 Form 4 DEP has provided this form for use by local Boards of Health. Otherms;m�� J information must be substantially the same as that provided here. Before using this form, cFiith 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 r ( �� C�G� S'✓ key to move your Address cursor return not Axe key. use the return City/Town �` State Zip Code 2. System Owner: Name ienan 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: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): `54, `'�5'r �/� � -- 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 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 So.Mill St.,Bradford,MA /ignat4,-reHauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts Tb VV01 0 r iVOM A n do for 0 City/Town of No. Andover System Pumping Record DEC - 2025 Form 4 DEP has provided this form for use by local Boards of Health. Other forms-4-M information must be substantially the same as that provided here. Before using this form,mc %entur 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, (to 1) 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: (N Name ienm ---------- Address(if different from location) --------------- City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: d 0 Date Gallons 3. Component: F1 Cesspool(s) El Septic Tank El Tight Tank El Grease Trap g Other(describe): .......... S I L)A 9 4. Effluent Tee Filter present? F-1 Yes R No If yes, was it cleaned? 0 Yes El No 5. Observed condition of component pumped: 9 OQ8, 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: CL 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 qy�_Dyj_ 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 �� /U�/� n��L.�, —'. c/ /�U/T� �=�- ��C�nwe��|+h of Massachusetts ~'��ker | ' ��' r�� ^|i�l | ��V|| ��/ 0�r ~ "�� ?0vc ��s�� K��~�� m� System Pumping Record Form 4 ��- DEP has provided this form for use by local Boards of Health, Other forms may beueed. butthe �""«�/��»� 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 310 CN1R 15.351. � ! A. Facility Information Important:When | filling out forms 1. System Location: � on the computer, 5t use only the tab � key Vo move your Address � cursor-do not No� Andnver MA 01845 use the ngum | key. City/Town s� � Zip Code 2� System Owner: Name Address(if different from location) � City/Town State Zip Code Telephone Number B. Pumping Record ~.� | 1. Date ofPumping Do�` 2� C)uenU� pumped: ��|hno 3. Component: [l Cesspool(s) Septic Tank El Tight Tank Fl Grease Trap POther(describe): 4. Effluent Tee Filter present? Ej Yee No If yes, was it cleaned? F-1 Yes El No 5. Observed condition of component pumped: � 00 �— —All of this estimated information is non-bindinq, valid only at the time of pumpin_g. N beyond the date above. 8. System Pumped By: Name Vehicle License Number J&S Development Corp. d/b/e ShawerCe Septic Service 7. Location where contents were disposed: Stnwa|ƒa (3|obe| Environmental, LLC 20S Mill St., Bradford, MAO1O35 See above Signature of Hauler Date See above sign—atwr—e4Receiving—�acmiity(or attach facility—receipt)- Date ............ t5fonn4doo` 11/12 System Pumping Record^Page 1of1 Vortf"A Commonwealth of Massachusetts ver w City/Town of No.Andover DEC m System Pumping Record 2025 Form 4 De DEP has provided this form for use by local Boards of Health. Other forms may be u ed bur nt 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, 7 1 1_ / I I 0 ` _WI use only the tab �] I W key to move your Address /� nn cursor-do not ❑� c�ove,( / V I A7 use the return City/Town /,, State Zip Code key. 2. System Owner: Name Henan Address(if different from location) No.Andover MA City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantit Pumped: �� U� Date y p Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap IOther(describe): v U A y e 4. Effluent Tee Filter present? ❑ Yes M No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 5 6. System Pumped By: Q oY� Name Vehicle License Number Stewart's Septic 58 So Kimball St. , Bradford,M_ A 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 �. ��J��j��H� ��f K�� rf&�- �Mm� Commonwealth. � Massachusetts� __ �~'^o'uVbY�� '+w/7~ f ^°' |`�' / ��\&/yl C�T � � � DEC��ste�� u��~�� Record " � � � y�c � Pumping - �"�� Mm � ! DEP has provided this form for use by local Boards of Health. Other forms muy��vu�� information must be substantially the same aa that provided here. Before using this form, ohmT0#19Wour 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 14daya from the pumping date in accordance with 310 CN1R 15.351. A. Facility Information Important:When filling out forms 1. System Location: | on the computer, | use on the tab/ ' | key mmove your Address oumu,'do not � No. Andover MA 01845 use the return | key. City/Town Gtoha Zip Code 2. Gvoham Owner: ["11�� ju_11,11y............-------------- Name Address| ` ' City/Town State Zip Code Telephone Number B. Pumping Record 1. Date ofPumping 2� Quantity Pumped: ` DateGallons 3. Component Fl Cesspool(s) 7 Septic Tank El Tight Tank 7 Grease Trap [� Other (describe): 4. Effluent Tee Filter present? El Yes 2 No If yes, was it cleaned? E] Yes E] No 5. Observed condition of component pumped: � 001 —All of this estimated information is non-binding, valid only at the time of pump ond the date above. 8. System Pumped By: Name Vehicle License Number J&S Development Corp. d/b/a Sb*wmrƒa Septic Service 7. Location where contents were disposed: Stewort'e Global Environmental, LLC 20 So. PWiU St. Bradford, MA 01835 See above See above Signature of Receiving Facility(or attach facility receipt) Date 0fonn4.doc- 11/13 System Pumping Record `Page 1of1 Commonwealth of Massachusetts f'60 Ver City/Town of No. Andover Dec 2025 System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, Wnw 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 2 S 1 ej key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code ........... key. tin 2. System Owner: ------------ k(" Name retwn .............. 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: El Cesspool(s) El Septic Tank F-1 Tight Tank F Grease Trap F-1 Other(describe): 4. Effluent Tee Filter present? F1 Yes F1 No If yes, was it cleaned? El 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 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: Stewar's G bal Environmentat,-�LC 20So. t., Bradford, MA 0,1835 See above .......... 7- ure o auler Date X See above /- ------------- Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc- 11/12 System Pumping Record-Page 1 of 1