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HomeMy WebLinkAboutJanuary 2026 Bake and Joy - Septic Pumping Slip - 351 WILLOW STREET 1/1/2026 Commonwealth f Massachusetts Town of Nofth Andover City/Town of No. Andover System Pumping Record - 2 2o26 FEB Form 4 DEP has provided this form for use by local Boards of Health. Other weg' '"'m5y'l"" '?c owl �ecP t information must be substantially the same as that provided here. Before using this orm, chec, 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 3 F�)] ............................. . ........................ ........................... ----------- ----------.............. key to move your Address cursor-do not No. Andover MA 01845 use the return .......... ....................... ................ key, Cityrrown State Zip Code W 2. System Owner.- Same . .................. Name few Address(if different from location) -.................... .......... ................ .. .... ...----------------------------------- City/Town State Zip Code -----------------------........ Telephone Number B. Pumping Record 1. Date of Pumping ...... 2. Quantity Pumped. _......... __ __... ...._. Date Gallons 3. Component: Cesspool(s) El Septic Tank 0 Tight Tank El Grease Trap ---------------------------------- Other(describe): - 4., Effluent Tee Filter present? Yes ET If yes, was it cleaned? El Yes 0 No No 5. Observed condition of component pumped: All of this estimated information is non-bi.ndin.g,,,.,,valid_,,,,only at the time of um,p,! onsible beyond the date above. _p _!Ig,,. Not res_p ........... ........ ............. 6. System Pumped By: .............................. Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service, 58 So. Kimball St., Bradford, MA 01835 7. Location where contents were disposed'. Sty art' Receivin Facilit , 20 So. Mill St., Bradford, MA 01835 ........... ........... ........ ........... See above Signature of Hauler, Date ------------ Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc- 11112 System Pumping Record•Page 1 of 1 P MP Commonwealth of Massachusetts Tot.v Of MOfth Andover City/Town of No. A,ndover System, Pumpinig Record FEB 2 2026 F'oirm 14 L DEP has provided this form for use by local Boards of'Health. Oth�ifaaii.*Oj- t r information must be substantially the same as,that provided here,. Before using t"t or , ,ATwith your local Board of Health to determine the form they use. The System Pumpi:ng Record must be submitted to the local Bcard of'Health or other approving authority within, 1'4 days,fro m the pumping date in accordance with 310 CMR 15.351. A, Facifity Information Important:When filling out forms 1. System Location- on the computer, use only the tab m.a ...... key to move our Address cursor-do not No. Andover MA 01845 use the return key, City/Town State Zip Code 2. System Owner., ........... ............................... .............. ...... .............................................. .......... ........... "At Name ............ .......... ............ .................. ................... ....................... ...........................--------- Address if different from location) City/Town State Zip Code ........................................ Telephone Number B. Pumping Record 2,. Quantity Pumped- 1:. Date of Pumping Date Gallons 3. Component. El Cesspool(s) E] Septic Tank E] Tight Tank El Grease Trap O u .............. ........... ............ther(describe): . 4. Effluent Tee Filter present? El Yes M No If yes, was it,clea,ned'? Yes No 5. Observed coinId!liti n of'compon nit pumped: All of this estimated information i's non binding lid e f g., va only at,the tim o iqg. Not respopsible..bey d the date above. _yMp 6. System Pumped m Name Vehicle License Number J&S Dievelopimerat Corp. d/b/a Stewart"s Septic Service ­--­­'-- . ..............."""7 Location wh re contents,were disposed* Stewart's Global Environmental, LLC 20 Bradford,, MA 01835 So. Mi:ll St.1 `70-r\e's See above Signature of Hauler Date See,above Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc*'11/12 System Pumping Recorde Page 1 of'l It gals ; is 0 Wn Of'V011 A d, City/Town of No. Andover 0 Ver tem Pumping Record fto FEB, 22026 Form 4 DEP has provided this form for use by local Boards of Health. li Oth it e butthe information must be substantially the same as,that,provided here. Before, using i§llfus"f k with your local Board' of Health to, determine the for�m they use. Tihe System Pumpling Record must be submitted to the local Board of Health or other apiproving auth�ority withini 14 days from the pumping date in accordance,with 310 CMR 15.3511. A., Facility Information lmpiortant#When filling out forms, I., System Location: on the c,ompute!r, "3 1 useonly the tab, ..............................----------------------------------------- ........... .............. key to,move your Address, c,ursor-do not No. Andove�r MA 01 1845 use the return .............. ...... .......... key. City/Town State Zip,Code 2. System Owner': f .......................................... ...................................................................---------------- .......... ................................. Name ................................ ......... ....... Add,res,s(if'differenit from location) .......... .................... ....................................... ........... City/Town, State Zip Code ................................... ........ ...................................----............... ............ ...... Telephone Niumber B., Pumping Record 7 0 0 1 Date of P,ulmpling', Date 2. Quantity Pumped. Gallon-s ...... 31. Component* Cesspooll(s) Septic Tank Tight Tan! se Tr�ap S I ........... Other(describe)" Effluent'Teei Filter present? 0 Yes, No If y,es, was it cleaned? IIYes No 5. Ob�servled conidition of component pum�ped* All of this estimalted information is non-bindi�,ng, valid"'only','at the time of in e bey, nd the date above�. _p g. Not reisp,onsibi ---------------------------------- 6. System Pumped ................. ........ Name Vehicle License Number J&S Development Corp. d/'b/a Stewart's, Septic Service ........................................... 7. Location where cont,en�ts were disiplose : Stewart 11 is Global Environmental, L,LC 20 �o. Mill Sit., Bradford) MA 01835 ............ ......... See above ----------- Signature of Hauler, Date See above, ...............-------------------- ........... ........ .............. ............ .................................... Signature of Receiving Facility(or,attach facility receipit), Diate t5form4,doc*11/12 System Pumping Record#Page 1 of I Town of A410rth An Commonwealth, f Massachusetts, doVer rMi City/Town of No Andolver FEB System Pumping Record 22026 Form 4 -3 DiEP has, provided this,form for use by local Boards of Health. Other forms may be use'd"I"bu''At," ent info�rmation must be s,ubstan�t�ially,the same as that provided here. Before using this form, check with your local B and of'Health to determine the form they use. The System Plumpi `ug Record must be submitted to the local Board of Health or other approvi�ng authority within 14 days from the pumping date in accordance with 3101 CIVI R 15.315 1 A. Facillity Information Important:When filling out,forms, 1w System Location-, on the computer, use only the tab key to move your AdIdress, cursor-do not No. Andover MA 01845, use the return key. City/Town, State Zip Code 2. System Owner-. Same ........... ...................................---------- ................................ ................................. Name ...................---------- ...................... .......... Address(if different from location) City/Town State Zip Code Telephone Niumber B. Plumping Record 2. Quantity Puimped: Date Gallon,s 3. Component: l(,$) [:1 Septic Tank E] Tight Tank 0 Grease Trap, 2 r(d�escr�ible).- ............. ......0000�th e 4. Effluent Tee Filter present? Yes No, If yes,, was it cleaned? Yes [:] No 5. Observed condition of component pumpedi- AOO All of this estimated information is non-bindingyalil.- -.,,..,pu,MP1,i,-n- .......... on�y at the ti -,e,,,of Not responsible bey,9n,d the date above. .............. 6. System Pumpled By: ---------------------------- Name Vehicle License Number J&S, Development Corp. d1/b/a Stewart's Septic Service, 58 So. Kim ball St., Bradford,, MA 018,35 -1-1------------- -------------, ......--............ 7. Location,where contents were,disposed, Stewart's Rece'ivi,ng,,,,,F'acilit,y,,,,,,,,201 So. Mill St.,,, Bradford, MA 018315 ---------- See, above // 13 - 2 / � , - Signat,ure of Hauler Date ----------------------...... ....... ........... ......... Signature of Receiving!,Facility or attach facility rec,eipt), Date t5form4.doc,11/12 System Purnping,Record Page, I of 1 I Town of A, Commonwealth of' Massac,husetts4 r �wA ndo Ver t,y/T'own of NoAndover ------------ FE81 System Purnpiin�g Record 22026 Foirm 4 Hie,91 94 DEP has provided this form for use by local Boards,of Health. Other forms it the Afore using Via tNith your information, must be su�bst�anitially the same as that provided here. Be this form local Board of Health to dei ter m�in�e the form they use. The System Rimpingi Reic,ord must be submitted to the local Board of'Health or other approving authoirity within 14 d i y from the pumping date in accordance with 310 CIVIR 15.351. A., Facility Information Implortant:When tipping out forms 1. System Location on the computer, use only the tab V key to move your cursor. do not use the return ....... key. Ci!ty/Toiwn State Zip,Code 2. System Owner- ? Name Address(if differeiv from location) NItrdr MA Cityffown State Zip Code Telephone N;1Jrnbier Bi. Pumpling Record 1 Date of Pumping Dat 2. Quantity Pumped: Gallons 3. Compioneint: Ces,s,pool(s) Sept,ic Tank TigihitTanik Grease Trap 6�1)4-t lt�clf 7 A:z (describe)* 4. Effluent Tee Filter present? If yes, was it cleaned? Yeis Yes �� No N o 51. Observed condition of component pumpied- 61. System Pumped By.: Name Vehicle License Number Stewart's S,ep 58 So Kimball Sit. Bradfoi ,MA 7. Location 'where contents were disposed: 20, So.Milli St.,Bradford,MA oi �31 ignature of Hauler Date signature of Receiving Facility(or attach facility receipt) Date t5form4.d:oc,o 11/12, System Pumping Record Page 1 of 1 Commonwealth of Massachusetts Town of Nofth Andover City/Town of No. Andover System Pumping Record F'EB 2026 Form 4 DEP has provided this form for use by local Boards of Health., Othe t the inf'ormation must be substantially the same as,that provided here. t wi th 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 2. System Owner- Same Name Address if different from location) City/Town State Zip Code .......... Telephone Number B. Pumping Record ? 1. Date of Pumping D,ate 2. Quantity Pumped: 3. Component- Cesspool(s) Septic Tank Tight Tank N Grease Trap 4. Effluent Tee Filter present? [:1 Yes., No If yes, was it cleaned? Yes 5. Observed condition of co, ponent pumped. - All of this estimated infor7gq� is non-bindin valid onl at the time of Not res onsible beyond the date above. p,_ympin�g_ ... ......... ............— 6. System Pumped By, Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service, 58 So. Kimball St., Bradford, MA 01835 7. Location where contents were disp used: Ste wart's Regea 0. ill St., Bradford, MA 01835 all OD<! Si nature See above Da t e" u�re o�fHauler�� Signature of Receiving Facility(or attach facility,receipt) Date t5form4.doco 11/12 System Pumping Record Page 1 of 1 Town Of North ()Verr Commonwealth f Massachusetts C"Ity/Town of No. Andover to 1 11 FEB 2 20126 Syste�m Pumping Record I.....-=..... Hea Fo i ...... irm 4 1Y .1 rt DEP has provided this form for use by l cal Boards, ofHealth. Other forms may be used, but the e i�nfoirma,tion must be, substantially the same as,that prov�ided here. Before usi�ng this form,, check w,ith! your l I ocal Bard of Health to determine the form they use. The System Pumping Recoird must be submitted to the local Board of Health or other ap!p�rolving authority within 14 days from the pumping date iln accordance,with 310 CMR 15!.3511 A. Facility Information Important:When filling out forms 1 System Location: on the computer, use oinly,the ta,b 7,) Ul .......... ..................... ................................................ ..................... ................................................ key to move your Address cursor-do not N�o. Andover MA 01845 use the return ............. ................................ ------ key', City State Zip,Code 2. System Owner:, W P Same -4,, jo(, . ... ........................................................................... J .................... -------------------- Name ........................... ................................................................................... .......................................................---------------------................... .................... ........... Address,(if different from location) ............. .......... ............................................................ .......--........-....................................... City � m__.�_........�.�.�.� /T'own State Zip,Code ......................---........................... ........ .................................. Te,l�ephione Number B. Pumping Record 7 . ---------------------- I, Date of Pumping ----------.................................. 2. Quantity Pum!ped�: Date Gallons 3. Component: C,esspoolI(s), 0 Septic Tank E:1 Tight'Tank Grease Tr�ap Other(describe),- ............ ........ ...... ... .................................................................................................................. ............ 4,, Efflueln�t Tee Filter present? 0 Yes 01 If yes, was, it cleaned? El Yes [allo 51. Observed condition of component pumpe& All of this estimated ponsiblip b yond the date above 6. tem P ped B 2.................................... N�ame Veh, ense Number AS Development,Corp. d/b/a Stewart,'s Septic Service, 58 So. Kimball St,., Bradford, MA 018315, T, Location,where contents we!re disposed: Stewairt's Receivp' q,,F-a1cA 0. M,ill St., Bradford, MA 01835 See above Signatt Date ---------------- ------- ------------- ........... ...... Signature of Receiving Facility(or attach facility receipt) Date t5form4,doc,,11/12 System Purnping Record Page 1 of 1 Town Of'North Andover Commonwealth of Massachusetts FE6 -2 2026 City/Town of' 'No.Andover System, Pumping Record th Depa Form 4 Heal rtM en 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 us,ing 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 approw inq authority within 14 days,from the piumpling date in accordance with 310 CIVIR 15.351. A. Facility Information: Important:When fi 1 1. System Location', i1fingi out�fo,rms on the comiput,er, use only the tab key to,move your Addrees, cursor­do not use the return key. City/Town State Zip Code 2. System: Owner: JA Name Address if different from location) i No.An�dlover MA Cif y/Tolwn State Zip Code ..... ..... WP 4,111M��111, WiN Bi. mipin,g Record 001 1,. Date of Pumping 2antity Pmped�: Date . Qu u Gallons 3. onilent: Cesspool(s) septic Tank Tight Tank Grease Trap Other(describe), 4. Effluent Tee Filter present? El Yes No If yes, was, it clean d? Yes No 5. Observed condition of component piumped, 16. System Pumped By: Name Vehicle License Number Stewart's Septiq_58 So Kimball, St. Bradford,MA Company 7. Location where contents were disposed-, 20 So. ill St.,BradfordMA Siginature of Hau]ie/ Date Signature of Receiving Facility(or attach facillity r�eceipit), Date t5f6rm4,doc*11 1/12 System Pumpling Record: Page 1 of 1 Commonwealth, of Massachusetts Town Of A10*Andover City/Town of No. And�olver FEB - 2 2026 System Pumping, Record Form 4, apartraent DEP has p�rovi'de�d this form for use by local oar ds of H'eaIt. Other forms, may be use , but the i,nfo�rmation must be substantially the same as that provided here. Be,fo�re using: �th�is form, check with your local Boa,rd of Health to determine the foirm they use. The Syste in Recor itted to the local Board of Health it other approving, authority within 14 days from the pumping date in accordance wit . A., Facility Information Important:When filling out forms 1. System Location- on the computer, key to move your Address cursoir-do,not No. Andover MA 01845 use the return .......... key'. City/Town State Z,ip Code tab 2. System Owner, & Same Name ............ ------------.............. ........... ....................................-........................................ .......................... ...... Address,(ifdifferent from,lio�c,ation) City/Town State Zip Code Telephone Number .................MM six � ng Re 'oird''! ( -, eZ-,,o 2 61 1. Date of Pumping 2., Quantity Pumped, Date Gallons 3. Colrnponenlit- Cesspool(s,) S,ep,ticTa,nk El Tight Tank 0 Grease Trap LJ ............. 2-00�ot er(describe),- ....... N o 4. Effluent Tee Filter present? Yes, jt4 If yes, was it cleaned? [:1 Yes, E No 5. Observed condition, of component pu�mp�ed: All of this estimated m !m in resp nsi,blie bey information is non-bindi valid on l,y,,,.at the ti e.."'of ............................................................... _p...... --ond the date above. ...................................................................... 6. System Pumped By'� 00 4,10 -�j 1-1-Y-241-------- ........... Name Vehicle License Neu mber J&S, Development Corp. d/b/a Stewart's Septic Service, 58 So. Kimball St., Brad'ford, MA 0183�5 11................. ............ 7. Location where,conten!�ts were disposed: Stewart's Receivin, Facility 20 So. ill S,t., Bradford,, M,A 0181351 .......... Mi....... C"-�- '00 See a-blolve". Signature of H auler Date ................................ Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc-,11 A 2, System Pumpiong Record Page 1 of 1 rown of Commonwealth f Massachusetts o jV A do Ver All A Y Cit /Town of No.Andover W aFES �, . Record 2026 Form 4 Af V y`'W Health DEP has provided this form for use b local Boards of Health. Other forms ma 8@ the p Y Y ��,� 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 Cityrrown State Y Zip Code key. rib 2. System Owner: IU VILL Name y few Address(if different from location) No.Andover MA City/Town State Zip Code S ..a Teleohone Number ,..., B. Pumping Record /IC 1. Date of Pumping Datd 2. Quantity Pumped: Gallons 3. Component: F-1 Cesspool(s) ❑.} Septic Tank ❑ Tight Tank Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes'M No If yes, was it cleaned? [❑ Yes ❑ No 5. Observed condition of component pumped: �A� Ij 0. jo Pumped By: Name Vehicle License Number Stewart's Septic 58 So Kimball St. , Bradford,MA Company T - 7. Location where contents were disposed: 20 So.Mill St.,Bradford,MA 5-tz ignature f Hau Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11112 System Pumping Record Page'I of 1 n of iVortl�lArldoVer :)w Commonwealth of Massachusetts City/Town of No. Andover FEB 22026 System Pumping Record Form 4 ea/th DePartrrl 'Af DE P has provided this for for,use by loc al Boards of Health. Other forms may be used, but the Gilt 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 cursor­do not No. Andover MA 01845 use the return .......... ------- key. yown St-_ate Zip Code 2. System Owner* 18b Same ............... ............. ---------- Name Address if different from location) City/Town State Zip C ode Telephone Number R. Pumping Record 1. Date of Pumping Date- ...... 2. Quantity Pumped- Gia.lions 11-11--111-1--l- 3. Compon nt* Cesspool(s) Septic Tank Tight Tank Grease Trap 0 Other(describe). 4. Effluent Tee Filter present? El Yes a No If yes, was it cleaned? El Yes El No 5. Observed condition of component pumped: All of this estimated information is b non- ng valid only at the time...of.. �"!.n� N .9-n.sible b ond the date above.ot resp 6. System Pumped By: 00e I Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service, 58 So. Kimball St., Bradford, MA 01835 T Location where contents were disposed: Stewart' ceivin acil. .y So. Mill St., Bradford MA 01835 ......... �2 1000? See above iagnatLre of Hauler Date Signature of Receiving Facility or attach facility receipt) Date t5form4,docs 11/12 System Pumping Record Page 1 of 1 11 9 V1 lortb 4, /7do vel* �LCommonwealth of Massachusetts City/Town of No. Andover 2026 SystemPumping Record Form �Afrr DEP has provided this fora for use by local Beards of Health. Other forms may be used, but the information must be substantially the sane 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 farms 1. System Location-, an the computer, use only the tab .. _.._. _._._...._._._ _ ____ u__._ ..._._.._.._..__..__. .. _ __.._._ ..�. __....._... _ M._.... _._._ ley to move your Address cursor-do not o. Andover ►1 45 usethe return ( itiluv _.______.w.______._______________ ._______.._._.. _. ...__..._._.w._..__..___._. .._a.._.M.__..n. _.______._..___._._.__...__.__._______.____..________._e___ _.___.__...._.. e key. State Zip Code tab 2. System ner- w rr.. _ .__._.__ . ......._._. _ _ .. ___ _ ....._ ___. ...w._ ._. .._ .__._._.______m_. ._.___ _f __._. .. __.__..._.::__.__. Nerve ....... ....... Address(if different from location) ityl"I"ernn__.__.__._.._ ...._. ._.._.... .............._. ._ .._.....___.__._.._______.____.__.____..__-______..... ..__.�_.._ _Mete..__...µ.___..._. ...._m__.m. ...._....._._.______.__..__... .__._______ .._n.__.____...__.___...___ .... ,dip code Telephone Number ......_...._....__...._...wm.�... __....W. ...._.._..._ ._w..__.. ._... ___....n_. B. Pumping Record 1. Date of Pumping �-..Date.__.______._._._.._��___._____�__.___.�..�_�. 2. Quantity a rn pad w __._ -�elIons .........___..............._ 3.. Compen,en Cesspool(s) Septic Tank Tight Tani Grease Trap 0 r <�V,Ojc ther (describe): 4. Effluent Toe Filter present? M Yes If yes, was it cleaned? E:1 Yes El No 5. Observed condition of component pumped: :�iee All of this estimated _information_ is_no.n.-bi d.Mn valid id only time . ..M :.... ___... _ __...t � r � y - - . rdt�� t- ._v�W.m. .._ 6. System Pumped ' y- Nerve.... _._. Vehicle License Number &S Development Corp. d/b/a Stewart s Septic Serv.......................ice, 5 So. Kimball St., Bradford, 01835 ........ ". Location where contents were disposed: Stewart's Receivin Fa ..20 So.-- ill St., Bradford, MA01835 Sao above'0000- Signature of Hauler Cate .......................... Signature of Deceiving Facility(or attach facility __M...._._._..._..�__..._ _.__._______.__�__.__.__._ ._...._.... .�..._...a._. ......_._._..._. .._..._. __.�mm_._..__._. .. _.___. ._ _._._...w ...._. _..__................._ ....... y( y receipt) Date t5form4.docw 11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massach u setts �,; Andover City/Town o o.And yer System Pumpi erd FEB 2 2026 Form 4 DEP has provided this form for use by local Boards of Health. Other f()�rms may be uS t? &cVgW your V�p information must be substantially the same as that provided here. Before using this form,The 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 GIVIR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab Ice to move y our Address cursor-do not use the return key. City/Town State Zip Code tab 2. System Owner: Name Address(if different from location) No.Andover---,.--,-- MA City/Town State Zip Code Telephcne Nul-r-ber B. Pu mping Record 1. Date of Pumping lla� 2. Quantity Pumped: Gallons 3. Component- spool(s) Grease Trap Ces Septic Tank Tight Tank (� Other(describe). 4. Effluent Tee Filter present? E] Yes No If yes, was it cleaned? Yes No L__J 5. Observed condition of component pumped- 6. System Pumped By: Name Vehicle License Number Stewart' Se tic!8 Sq Kimball St. Bradford,MA Company 7. Location where contents were disposed, 20 So.Mill St.,Bradford,MA 40 6 pne, Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doco 11/12 System Pumping Record-Page 1 of 1 Town of Itj A Commonwealth of Massachusetts ndover C*ty/Town of No., Andover_m I 2026 FEB System n Record Form 4 Health Departm r DEP has provided this form for use by local Boards of Health. Other forms m ay be used, b6q U ie 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 data in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1, System Location- t on the computer, �2 use only the tab ........................... key to move your Address cursor-do not No.the return Andover, MA 01845 use key. City/Tolwn State Zip Code 2. System Owner- tab WGI Same ............ Name MMA -------�if....Address different from location) ........... City/Town State Zip Code ................................. .......... Telephone,Number B. Pumping Record CIO 6) 1 Date of Pumpin teg .........................- 2. Quantity Pumped: ............... Da Gallons 3. Component, Cesspool(s) Septic Tank Tight Tank Grease Trap Other Alz ------------------------ other(describe)- ........... 4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes [1 No 5. Observed c ndition of component pumped: All of this, estimated information is non-binding valid onl at the time of Not responsible 1��y nd the date above..,.. responsible.. ........ ,_ym g -PT 6. System Pumped By: .......... Name Vehicle License Number J&S Development Corp. d/b/a Stewwart s Septic Service, 58 So. Kimball St., Bradford, MA 01835 .............. 7. Location where contents were disposed: Stewart's Receivin Facilit 20 So..m..Mill St., Bradford, MA 01835 See above Signature of Hauler Date ................... Signature of Receiving Facility(or attach facility receipt) Date t5fo rm4.d ocs 11 12 System Pumping Recordo Page 1 of 1 Commonwealth of Mas,^Z�o%chusetts Town of Nofth Andover City/Tow n of eP1 61 MAR 3 2026 System Pumping Rec ord Form 4 Department Healti DE P 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 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 CAR 15.351. A. Facility Information Imp rat:When filling out forms 1. System Location: on,the computer, M. use only the tab key to move your Address. cursor-do not use the return key. City/Town State Zip Code tab 2. System Owner: Name 61i_yffown State-—-------- Zi"p Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped- Gallons 3. Component- Cesspool(s) Septic Tank Tight Tank kIGrease Trap Other(describe)- 4. Effluent Tee Filter present? Yes 'No If yes, was it cleaned? Yes lie 5. Observed c ndition of component pumped: 6. System um p d B Vehicle License Number Stewart's Sep Lic_58-SoK.imbell St. , Bradford,MA Company 7. Location where contents were disposed: 20 Se. ill St.,Bradford,MA �ignature of Hauler Date nature of Receiving Facility(or attach facility receipt) Date t5form4.doc-11/12 System Pumping Record Page 1 of 1 A01111F, ()f 6W ��L-\ Commonwealth of Massachusetts 0 11 do Ver 2 2026 City/Town of No. over System Pumping Record Health Form 4 DEP has provided this for for use by local Boards of Health. Other forms may be used, but the t 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 A16W .......... key to move your Address cursor-do not No. Andover MA 0 1845 use the return ......... key. City/Town State Zip Code p tab 2. System Owner: Same Name Address if different from location) City/Town State Zip Code ........... Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped- Gallon-s 3. Component.: E] Cesspool(s) Septic Tank Tight Tank Grease Trap [� Other(describe): ­ ­­­­_ 1111-1-- 4. Effluent Tee F'ilter present? [I Yes 2 No If Yes was it cleaned? 0 Yes El No 5. Observed condition of component pumped- o o All of this estimated inform ation is non-binding) valid oral at the time of mping. Not resp ... onsible beyond the date above. .................... 6. System Pumped BY: h .......... ..................................... Name Vehicle License Number J&S Development Corp. d/b/a Stewart's Septic Service, 58 So. Kimball St., Bradford, MA 01835 ............ ----------- 7. Location where contents were disposed: Ste wart's R c i iru acilit u11 fit. Bradford, MAO 1835 /11 OL 0 �'O's See above Signature of Hauler Date ............ Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc,,11/12 System Pumping Record•Page 1 of 1 rown of lVorth 4n,dovgr Commonwealth of Massachusetts "ty/Town of No. Andover FEB 22026 System Pumping Record tl Form 4 11E?a1th DewPartm., t DEP has provided this for for use by local Boards of Health. Other forms may be used, but the 17 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, V./ �4­ 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 W 2. System Owner: Same Name Address(if different from location) ................... .......... ................... City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date...._ .......... 2. Quantity Pumped. Ga-lions 3. Component- E:1 Cesspool(s) Septic Tank E] Tight Tank 0 Grease Trap Sj Other(describe): ....... 4. Effluent Tee Filter present? D Yes, No If yes, was it cleaned? Yes [] No 5. Observed condition of component pu ped* 00a, All of this estimated information is non-bindin , valid only at the time._of i,nq.. Not responsible beyo.p.d...,.th,.e.d ate 6. System Pumped By: Name Vehicle Lic ense Number J&S Development Corp. d/b/a Stewart's Septic Service, 58 So. Kimball St., Bradford, MA 01835 7. Location where contents were disposed: Stewart's, Receivin aq�ilit 20 So. Mill St,., Bradford, MA 01835 ­­ ­­.I-�- � � I­­­­­­__ __g f_!­__y ......------ So v7 _jPcn6 See above Signature of Hauler Date ----------- ........................ ................ Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc* 11/12 System Pumping Record*Page 1 of 1