The URL can be used to link to this page

Home My WebLink AboutDecember 2025 Bake & Joy - Septic Pumping Slip - 351 WILLOW STREET 12/1/2025 Commonwealth of Massachusetts City/Town of No. Andover System Pumping Recor �Af TM Form 4 C EP 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 Pu AOWtted t t � c��l Ord Healthr th�r r�vr� �uthrt within 14 � �frr the � �� accordance with 3,10 CM R 15.35 A Facility Information Important:When filling out forms 1. System Location: P 7 nt on the computer, zuse � �.. onlythe tab ..._....... ..�.. .._. _.�_�_... ._... . ...__.._ ..._..m....m......____......._......_._...._��.... ...._.......... �.._._._...M...�.......... _.�� _.......�.... _... ..��......N... .._ .�� ;....._ _-___w_.__._......._._ .....��........ __.�........... �.._�...._.....�_. a ...... ... key to move your Address cursor not o. Andover 01845 usethe return __._.._......._....__..... .......M.._.._. ....._.... .... ..._.. .......w._..w .._ ...__..-......... ----- key. City/Town State Zip Code 2.. System Geer: tab icy- . .. _ . . ....... .. ._....__._._.._..�.�.� Mama Address(if different from location) City/Town State Zip Code __._ ........._..... _w wm_ _...____.__......_m_. __ _ _ __.... _..._. ....M Telephone Number Pumping ,ram F 1. Date of Pumping Date _.__.........� .._.._...:...w. 2. Quantity ty Pumped: Gallons ._.....m_..._ ..._.ry..._ ._...._ .M.._.w......... 3. Component.- Cesspool(s) El Septic Teak 0 `fight Tank CreaseAffl....;.re, "rap Roo�� _.�w....�... _.. Cher descri d . .._....... ____w_� ..__.... .� �_.. _._.._.�...... .�.... :....._... _._..... ._....._..w...-_-_____.. .m...__-�_..� ..... . _. �._.. ..... . Effluent Tee Filter present? Yes No if yes, was it cleaned? Yes, N 5. Observed c ndition of componentpumped- All of this estimated information is n-bi .d.l valid l y at the time um pi Not res p sl�ble � end the date above. ..........6. System Pumped : ._.r... . .....__._.. _..._......� -..m.__ _.._ _._ _......_.�...........w....._. _.... __r._.....__.._._..._. . Name .Vehicle License Number &S Development Corp. d d a Ste a "s Septic Bernice 7. Location where contents were disposed: Ste art"s Global Environmental, LLC CSo. _._:ill_fitBradford,.. 01835. ... ..._.._... ._... ..........._........ ........_....._..._w_.._..-___._..._...__................._..._.. ._ _ .._.._._._.._.._......mm ..... above .... .... _.w _._._ ___ ...._.�....._.... _...._ .. _�... . _..._...-___w.._..._ ee ....................... Signature of Mauler Date 0 _....M._..__......._M....... _...w...._. . -_-._____r...... _..._.. ._.. _._..__ _.__._. .._. I . m_.... ...............a......_....... __�. Signature of Receiving Facility or attach facility receipt) Date t5form4. ac•11/12 System Pumping Record.Page 1 of 1 Town of N'ofth Andover Commonwealth of Massachusetts, F4 City/Town of ver t lin rd JAN 5 2025 OQ Form 4 DEP has, provided this form for use by local Boards of Hie alth�. Other`i8ffit MIWWkA iln%ut the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to,deter mi,ne the foirmi they use. The Systemi Pumping Record must be submitted to the local Board of Health or other approving authority with�in 14 days from the pumping date in accordance with 3,10 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, use the return key. City/Town State Zip Code 2. System Owner: VQ Name loon Address,cif different from location), No.Andover MIA City/Town State Zip Code Telephone Number B. Pum ping Record 1. Date of Pumping Date 2. Quantity Pumped. Gallons -ompo n Grease Trap 31. Com!pon t" Tight Tank Cesspool(s) Septic Tan Other :t,her (describe) 4. Effluent'Tee Filter presen�t? Yes �o If Y es, was it clea,ned? N o Yes 5. Observed condition, of component pumped- 6. System Pumped By-' Vehicle License Number Stewart's Septic 58 Sol Kimball St. , Bradford,MA, Company T Location where contents were disposed: 20 S,o.Mill St.,BradfordIVIA Signature of Hauler, Date Signature of Receiving Facililty(or attach facility receipt) Date �.. �.�r_W_�� t5form4.doce 11/12 System Pumping Record-Page 1 of 1 Commonwealth of Massachusetts Town of Nofth Andover City/Town of No. Andover SystemPumping Re Form DEP has provided this form for use by local Boards of Health. the information ation ust he 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 t 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 Infor Important:When filling out forms 1. System location: on the computer, ,e only the tab key to rare your Address cursor-do not No. Andover 1845 use the return _w.w... . .......w. ...�...w... ...� ..�.._.._......_....._..m.._....__._._...._.. _. ._...._.__......... _.......... ......_w. key. City/TownZip code 2. System O ner- � Tare . _ _._...._ __........ _..... ..._..._ .._...._.... .......... ......._w..___.._ _._._ .___ __. .. Address(if different from location) State Zip :ode TelephoneI' rrber._.n�_w.____�_.___-___.�___.._....._..�___._w_.�..�...�.rv.��,..._.a._a ..._...... ..��..�..�_....�.�....�....... B. Pumping Record 12, 1. [fate of Pumping Date _...:._ �._.._.._..__M..M... __.... � Quantity, Pumped* �_� _.__.M.__......_....._.. .� Lallans 3. Component: Cesspool(s) Septic Tani right rank F� Grease Trap [�J�bther(describe). 4. Effluent Tee Filter presents Yes If yes, was it cleaned? Yes N . bser ed , nditi n f component pumped: G"" All of this estimated lnf ar ati_ n l.s,_n....o....n_..._.b__.in_.d_.._l...nw. , valid n at the time'.of ..__. a._mt._.responsible beyond the date a ew _ 6. System Dumped 100 ... .......... __.a............._.._ �...._... __.....m. .-.____. __..... .. .__..... _._.__......._...._ _.. ... _ _ _ ...... .._._._ _ ....__ _..__.._.. .._.._._ ..__...._w........ Larne, Vehicle License Number S Development Corp. d b/a Ste art's Septic Service 7. Location where contents were disposed: Ste arc's Global Environmental, LC t Bradford, 01835 r f . ......._..._......�........_...__...._._... _ _.�... _.�.........w..._._. 2 ... Mill .... .. ..... ......_. __....... .._.__. ._� _._ See mow.. ............ .. __._ __ _....... ......_...... _._............. _...._.w. ._._.. .. �u _....._. Signature of Mauler Date above _..µ.... ...._... _..__._.__.w...w....-_.______.___-__.-_ _.__-_..__._ ..... _..._... .. _..__ __.._... . ...._.. ._a.._....... ._.... .. ._..... .._... _..__..._ ._.._.._.._.._.__.._.._........... Signature ture of Receiving Facility(or attach facility receipt) Date t5farm4.dac•11l12 System Pumping Record.Page 1 of 1 Commonwealth of Massachusetts 70CVl of Nod Andover C ity/Town of No. Andover to > System Pumping Record JAN Form 4 H cl, ' DEP has provided this for for use by local Boards of Health. Other forms may 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. City/Town State Zip Code V tab 2. System Owner- Q ............ ........ --------- Name Address(if'different from location) .......... ........... City/Town State Zip Code Telephone Number ----------- B. Pumping Record 04 S &Nel 1. Date of Pumping 2. Quantity Pumped- Date Gallons 3. Component- Cesspools) Septic Tank Tight Tank Grease Trap e�jck Other(describe)* 4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes 0 No 5. Observed co Idition of component pumped: All of this,estimated information is non valid oply"at the time.of._pum,pjn bey...q. Not responsible _9nd 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.- Ste wart's Global Environmental, LLC 20 So. Mill St., Bradfc�r �A 01835 Z"-- .................. ........... ............ See above Signature of Hauler Date See above Signature of Receiving Facility(or attach facility receipt) Date t5form4.doco 11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts TOWn of Nofth Andover City/Town of No., Andover System Pumping "ecord rx JAN '2025 ......... Form 4 DEP has provided this form for use by local Boards of Health. Oth4feakfq information must be substantially the same as that provided here. Before using thiPMor' 4, f#with your local Board of Health to determine the for 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 V 2. System Owner- r 00, Name I ......................... ................................. Address if different from location) ........... City/Town State Zip Code Telephone Number B,. Pumping Record (00 0 1. Date of Pumping Date ....... 2. Quantity Pumped. 6 136o n�s�� 3. Component.- Cesspool(s) Septic Tank El Tight Tank 0 Grease Trap P'. " U Other(describe),-, ................ 4w Effluent Tee Filter present? Yes No If yes, was it cleaned? [:1 Yes El No 5. Observed condition of component pumped- 0,IL All of this estimated information is non-bindin , valid only at the time of ire ot responsiblebeyorid the date above. 6. System P u mped By: .................... .......... .................001M Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service 7. Location where contents were disposed- Ste wart's Global Environmental, LLC 20 So. Mill St., Bradford, MA 01835 ........... --------___..... See above ---------- ....... Signature of Hauler Date ........ ........�.��...w. See above Signature of Receiving Facility(or,attach facility receipt) Date t5form4.doco 11/12 System Pumping Record•Page 1 of 1 �Ifn Of 1VOrt6 An Commonwealth � p dover City/Town of No. Andover System Record Form m C EP has provided this fora for use by local" Boards of Health. Other forms may he use information rust be substantially the same as that provided here. Before using this fora, check w,qpkr local Board of Health to determine the form they use. The System Pumping Record rust be submitted t the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 C R 15.351. A. Facility Information Important:When filling out form '. System Location: on the computer, use only the tab ley to move your Address cursor-do not No., Andover MA 01845 use the return City/Town _.___.___.....__. ................._._. key. 2. System Owner: tab Name r Address different from location) _._.___...... .__.._ _ _ __....._..... .............._ ..... ..... ._. ._ _...u...__..._..__.___ _.w.w.__...w.. ... �............... _..._...w.___w__ ...... _.._...._ _..... City/Town State Zip Code ..............._._.._ .................... Telephone Number B. Pumping Record ate 2. Gallons 3. Component- Less ol(s) [:1 Septic Teak El Tight Tangy Grease Trap �t () Other describe 4. Effluent Tee Filter resent' 'des 21,No If yes, was it cleaned? Yes No 5. Observed condition of component pumped: 2 0 0 All of this estimated information i r er dNr der , veld oniv at the time of Not ry e ...... ..d .M. ery t e et above.. 6. System Pumped By. Vehicle/44 a's 0 , Name License Number S Development Corp., d d e Ste art"s Septic Service T Location on where contents were disposed* Ste art's Global Environmental, L.L C 20 So. Mill St., Bradford, ( 35 IA� .:1 011A ,3 ....... See e eve Signature..... .. . ... ...... ...__. ._. ......._. .__.__._..._..._.._. _......._ ....._ m. __. _ _.. f Hauler Date See above �Signature� f Receiving Facility car attach facilityreceipt) Date t5f .d c* 11 12 System Pumping record Page 1 of 1 Commonwealth of Massachusetts rOW17 OfAbH4' City/Town of No. Andover System Pumping Record J4 Form 4 2025 CHEF' has provided this form for use by local Boards of Health. Other forms94 d, but the information must be substantially the same as that provided here. Before using this k with your 's i 4 local Board of Health to determine the form they use. The System Pumping Record must Vb itted 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 Importaft,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 ---------- ....... -------- Address(if different from location) ........... ------------- City/Town State Zip Code ........... Telepho�ne Number B. umpire, Record 1. Date of Pumping 2. Quantity P umped- '��rbns Date 3. Component: E] Cesspool(s) Septic Tank Tight Tank Grease Trap --I UA 9 Other(describe). ...............-.......... ....................... ................. ......... ------- 4. Effluent Tee Filter present? 0 Yes d'No If yes, was it cleaned? El Yes 0 No 5. Observed condition of component pumped: 00L All of this estimated information isnon-bindin valid only__at the time of_p.um_pipg._Not re§p_q_psible be and the date above. .......... 6. System Pumped By: a 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 018�35 .......-------- Seeabove Sign ature of H a u ler Date See above .........._'_.'................... ............. Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc,o 11/12 System Pumping Records Page 1 of 1 Commonwealth of Massachusetts row/? Of North A/7do Vq City/Town AndoverJAN System Pumping RecordForm � rvr Af DEP has provided this form for use by local Boards of Health. Other forms may be used, b0twpt information must be substantially the same as that provided here. Before using this fora, check with your local Boards of Health to determine the fora they use. The System Pumping Record resat be submitted t the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CIVIR 15.3�51. A. Facility Information Important-When filling out forms 1. System ocatio�n w on the computer, use only the take key to move your address cursor-do not No. Andover I 45 usethe return ..... _.... ...._... ......._........_..............._..._.___.._.M_ .._. .._...__ .......a.....___.. __ w_............._...n_...m_ __...._.__. ._ ...._. ......_. _.._...._.._. ._._.__.. ...w key. City/Town State Zip Code VQ 2. System rover- ..... _.........._W......._.. _._...__.__.._. ...._........_..........__ _.. _....._..._.... ._. a._........_...,..__.. 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 3. Component: Ces,s i s Septic Tank Tight Tank erases Trap W0000ther(describe) ..... .. . _.. _.. .......�.__w._.......�. 4. Effluent Tee Filter present? Ej Yes 0 No If yes, was it cleared Yes [:1 N 5. Observed c ditl r of componentpumped* All of this estimated is r r-[ w rding,.�.valld..� �.n aime wr Not res orslblebeyOrd the date above. information _... ....... t the t f . ..... ...._ .µ...... _......�__._�?._._..._ "...�� _...._..._.._... _..........�.�_ ... ...� .... . . ..._....__..m_M_....._..�_ ...w....�_.... 6. System Pumped y. . mm..._... ...... _r.._..__.4.-__. ` w._..w_w_.__/40 ._.._.... ................._ ...... ___....MM..._.._._µ.. ._w.. ... _.. .__. .... _ .._...... . .. .____..M _.__.__ ....w._._.... ._.w....a. Name Vehicle License Number S Development Corp. d a Ste art's Septic Service . Location where contents were disposed: Ste a "s Global Environmental, LLC 20 So.....'...µroll St_, Bradford,...MAO 1835 See above Signature of hauler late See above Signature of Receiving Facility(car attach facility receipt) Cute t5fcrm4.dcco 11/12 System Pumping Record Page I of Commonwealth of Massachusetts TOW11 of NOfth Andover City/Town ►.Andver System Pumping Record 2025 JAN Form 4 DE P has provided this form for use by local Boards of Health. Other formhQyaW)j6");�' information must be substantially the same as that provided here. Before using this form, cheqc%,"tur 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 Addr s ar cursor-do not use the return Ivey.. City/Town State Zip Code 2. System Owner: Name Address if different from location) No.Andover MA City/T wn State Zip Code Telephone Number B. Pumping Record Z7 1 Date of Pumping 2. Quantity Pumped: Gallons 3. C Septic Tank Tight Tank Grease Trap ompone Cess po of(s) Other(describe)- ......... >, n other 4. Effluent Tee Filter present? Yes lie If yes, was it cleaned? Yes No 5. Observed condition of component pumped* & System Pumped By.- "�t .......... ------- Name Vehicle License Number Stewart's§Se 58 So Kimball St. Bradford,MA 7. Location where contents were disposed* 20So., St..,Bradford 6511 signature f gnature of Hauler Date Facility(or attach facility receipt) Date t5form4.doco 11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts To,wn of North Andover :� City/Town ofro No. Andover 52025 System Pumping Record JAN 4V Form 4 xw i7l Den ilifAnent DEEP has provided this form for use by local Boards of Health. Other forms may be, used-,"5djqiif 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 6 LIJ key to move your Address cursor-do not No. Andover MA 01845 use the return .......... ........... ----------- key. City/Town State Zip Code W 2. System Owner- (,/v Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. QuantityPumped. __ w____.._____...__M._.._____.__..m.___.M____..__... Date -6-a-llons 3. Component- Cesspool(s) Septic Tank Tight Tank Grease Trap 200�other(describe).- --------- 4. Effluent Tee Filter present? El Yes No If yes, was it cleaned? Yes N o 5. Observed cot Idition of component pumped: All of this estimated information is non-bindin , valid oq�y at the time_of.pumpina. Not responsible beyo�Rq the date above. --l-1-1.1.----------- ........... --------- 6. System Pumped By: ------................. ------- ....... a ermy e -Vehicle License Number J&S Development Corp. d/b/a Stewar's Septic Service -----------...........-------- 7. Location where contents were disposed: Stewart's Global Environmental, LLC 20 So. Mill St., Bradford 0183,+ ___..W _ _ . _5 See above Signature of Hauler Date See above ............. .............. ...............---------- ........................... Signature of Receiving Facility(or attach facility receipt) Date t5form4.doco 11/12 System Pumping Record Page 1 of 1 ON Ot Nofth Andover uo Ith of Massachusetts JAN - 5 2025 Ci ty/Town of No. Andover System Pumping Record 40alth De a 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 Address cursor-do not No. Andover MA 01845 use the return key. City/Town State Zip Code 2. System Owner.- VQ ............... ............ ------- Name Address(if'different from location) City/Town State Zip Code Telephone Number B."lPumpi,ng Record 1., Date of Pumping ... ...................... 2. Quantity Pumped- DateGallons 3. Component.- Cesspool(s) Septic Tank Tight Tank E] Grease Trap Lli-J 10091-cz; 20.'00�0ther(describe): 4. Effluent Tee Filter present? [I Yes V�.No If yes, was it cleaned? Yes No 5. Observed co dition of component pumped- All of this estimated information is non-bindin.g.,_valid only at the time of ump s I_'p _j.n.g. Not re ponsib e he nd 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, 0 1 5 ................................ See above o��.--��--- 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 I �� Commonwealth of Massachusetts�. TOMIn of Nod AndoVer /Town of N o., ovar Wks AN J 2025 System Pumping Record Form 4"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 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 CAI R 15.351. A. Facility Information Important:When filling out forms 1. System Location* on the computer, ")b use only the,tab I., '14/ key to move your Ada ad re s cursor-do not "" use the return St key. City/Town ate Zip Code 2. System Owner- Qt J? Name Address(if different from location) No.Andover MA City/Town State Zip Code ne Number B. Pumping Record '2 1. Date of Pumping 2. Quantity Pumped- Date Gallons 3, Component: Cesspo ol(s) -1 Septic Tank E] Tight Tank Grease Trap Other(describe): 4. Effluent Tee Filter present? Yes 0 If yes, was it cleaned? E' Yes I Jo 5. Observed condition of component pumped: 6-5---v 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.,411 St.,BradfordMA C Ile Signature of Hauler Date Signature of Receiving Facility(or attach facility receipts Date t5form4.doc-11/12 System Pumping Record•Page 1 of 1 Tolwn of Nofth Andover Commonwealth of Massachusetts City/Town of No Andover System Pumping Re2025 Form 4 DEP has provided this form for use by local Boards of Health. Other far �-iq4vbl-b LwPwtment information must be substantially the same as that provided here. Before using this farm, 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 ether approving authority within 14 days from the pumping date in accordance with 310 CAR 15.351. A. Facility Information Important:When filling out forms 1. System Location- on the computer, 9- use only the tab key to move your Address cursor-deg not No. Andover 01845 usethe return _... ....__._w._W..___. _W__ _... _.__w __.___._.._.___.._,___.___M_m.m_._,_...__.._._M._._...___.._.....__...._._..._ _._ ._®..._.w_....._. _. ... key. City/Town State ,dip Code W 2. System Owner: I/AV Name ... .w... __w_ww___ __ ._..__.m_..___._._..m....n_. _,....__.M..... _.m,_._ ...._.__ ____ .. _.. .Address(if different from location) ........ .. City/Town __ __- _ _,___._w __.__...w_____ __,.__........_.m ..._..nw_a...._.__ ._ ._._...._.....__._ State_ . _._____.___ ___.__._.. __._.__w.n_____._M_.._._._.___ did Telephone Number B. Pum' ping Record 1. bate of Pumping _._.��._�____._.._w_.__.. Quantity Pumped* C� . _ _._...M__�_.._._.__.._�._�____ �__�___M._-___-____._M. ....__.__... Clete �llons 3. Component- Cesspool(s) Septic Tank Tight Tank Grease Trap Me Other(describe). 4. Effluent Tee Filter present' [:1 Yes if yes, was it cleaned`'` "es El No 5.. Observed c ndition of component pumped. All of this estimated information is non-binding, valid oni _at the time of um �n Not re onsible be and the date above. -vw____-_____ _._ . __.._.M.M...._._.m..M__....._.M.__...w _ __ __.-___..__.1 __ _____�_m__._..w.._.._m. ._M ...___p.__.._ __._._._ __ .. w..eW ..u__.___ __._.........__ . System Pumped y: V wn Name Vehicle License Number ,J S Development Corp. d/b/a `tewart`s Septic Service . Location where contents were disposed: 'te rart's Global Environmental, LLC 2, S .IM ill Bradford, I/1 1835 _ _..m_.._..... _ _.._._._. _............._......._._..__ _.. —._.._.... _ - .._ _.,..._._...._..a._.,..________.._..._..m ....__.. ....IT.... See above ,�c5? "mature of Hauler Cate See above Signature of Receiving Facility(or....� _. ........._.�.....attach facility...w...receip.._ t) Gate t5form4.doc•11/12 System Pumping Record.Pao 1 of 1 Commonwealth of Massachusetts Town of Nofth Andover M CiyTownNo. Andover age _ ., 2025 V4 JAN System Pumping Record Form Icalth Departmg nt DEP has provided this form for use by local Beards of health. Other forms may �e used, but t e information must be substantially the sere as that provided here. Before using this fora, check with your local Beard of Health to determine the form they use. The System Pumping record must be submitted to the local Board of Health or ether 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: can the computer, use only the take key to move your Address cuirsor-d not No. Andover C 1 5 usethe return tityl�"awn _ _ _w_.._......_,..._.._....__., m_...._.. ......_ .w.._.._.,._....___._._.___.._.___.___.._....._.....__.._._.._.... ._._m..._ __.___.__,_,_,M_w___�__..._._...__.._ .._ _ i td State oe Icy, 2. System owner: t _._..__....._..__., _ __ _,. ...... Name I:RWA _._._m._ _..,_._._ -------- _.,._.. ._.__..._.._ _.__.w .._..._..._w..m.. .�.,....._ ...._...m..........._._.__. ._. __... __.___ _...._.__.._.._.....____.....mm _. ........_....__._...__..._. Address(if different from location ity .__ ________________.._.___.._,,.___..__.__._...__.._.....,._,_..___ _...._.._..w... cwn State Zip Code Telephone Number B. Pumping Record 1. Date,of Pumping ._. _�___.___.____...___.______..�_ �. Quantity Pumped: .�_..._ _��._..�_ ....__.....__ D�st� Gallons 3. Component: El Cesspool(s ) [ Septic Tank Fight Tank Grease Trap LA Other(describe): ...-.-.. -.--....-...._..._M.__..M.,..___.__,._.._____._________ __ . Effluent Tee Filter present? [:] `des No if yes, was it cleaned? No 5. observed condition of component pumped: c All of'this estimated .._.__..wM..._._.._P _ _ v___..____.._..n._m� _ _._.___. . .above. information is non-binding,valid onl e µ he time of m. rn . lot r�� on�rble be._o.n the ate _..�..._ .�_ .. 6. System Pumped By: Name Vehicle License Number AS Development Corp.. d/b/a Ste cart"s Septic Service 7. Location where contents were disposed: Stewart"s Global Environmental, L LC 2 o. hill St.b Bradford, l A 1835 _._ _ .. ___ _.. __.......______.__ low See above Signature of Hauler -D-ate_.__._ ........... Signature of Receiving Facility(or attach. .�_.._,._ ._.__....____ See above facility receipt) _Date t5fcrm4.dcco 1/12 System Pumping Record•Page 1 of°I