HomeMy WebLinkAboutFebruary 2026 Bake and Joy - Septic Pumping Slip - 351 WILLOW STREET 2/3/2026 Town
Commonwealth of Massachusetts
Of Nct)Andover
NoAndover
City/Town of
System Pumping Recormm
d MAR 3 2026
Form 4
At ;b
DEP has provided this form for use by local Boards of Health:. OtheN""J�*Paot
information must be substantially the same as that provided here. Before using this form,qcvftLith your
local Board of Health to determine the form tl' use. The System Puu mpin:g, Record must be submitted to
the local!, Board of Health or olth�er approving authority within 14 days from the plumping date in
accordance with 310 CC R 15.351!.
A. Facility Information
Important:When
filling out forms 1 System Location,
on the computer,
use only the tab -0,57,
key to move your Address
-do not cursor
61,
4e
use the return J)�
key. fit State Zip Code
2. System Owner-
Q ,
Name
Address it different from,location)
No.Andover___. MA
City/Town State Zip Code
Telephone
B. Pumping Recoird
1 w Date of Pumping Date 2, Quantity Pumped: Gallons
3. Component- �_._�.� essp Cool(s)
L. _] Septic Tank ....... Tilght'Ta Grease Trap
nk
4� 0 714
Other(describe),
S
4. Effluent Tee Filter presen�t? I No If yes, was it cleaned? es
Ye 0
Y No
51. Observed condlition of component pumped*
6. System Pumped By,
Nam Vehicle License Number
Stewart's, Se two 58 So Kimbal:l St, Bradford MA
P
Company
7. Location where cunt ents,were disposed-,
20 Sol.vill St.,Bradford,MA
go
Signatur
e of Had er Date
Signature of Receivin cilit r attach facility receip,t) Date
t5form4.doc#11/12 System:Pumping Record-Page 1 of 1
'0" 0 f IV011h A n do vjq1
Commonwealth ofMassachusetts,
City/Town of No�. An�dover
MAR 3, 20
it
System Plumpling R ,%.vrd, 216
Q, Fo:rm 41
De
D,EP has, provided t,h�is form for use by local Boards, of'He�alth. Other forms may be used, bU'f f,pint
in format'ion must be substantially the same as that provided here. Before in thli firm, check with your
local Boardl th to determine,the form they use., The, Syst rd must be submitted to
the local Board of'Health or other approving authority within 14 days from the pumpire te i�n
accordance w,ith 31�O CIVIR, 15.351,
Facility Information
Important:When
filling out f61rms 1. System Location',
on the,cter
use onlIy the tab, ........................ -----------
key to move your Address
cursor-do;not No. Andover MA 011845
use the return --------
key. Citly/Town State, Zip Code
tab 2. System Owner.-
Ica b
Same,
..................... ........... .......... ............................Name
..................................... ...............................
Address if different from location)
....................--------------------------- ............................................................. .......... ...............
City/Town State Zip Codlie,
_11111...............
Tel ne Ni r
B, Pumping Record
3
............................. -----------------------
1 Date of P�umping Date 2. Quantity Plumped. Gallons,
3. Component- Gasp ooll(s,) Septic Tank Tight Tank Grease,Trap
2'0'0�0ther(describe): ..... .......... ........... ...........
4. Effluuen�t Tees Filter present? 0 Yes &No If yes, was it cleaned? El Yes 0 No
5. Observed condition of component plumped:
l of this estimated
information is nonb_in.ding_, vaI on,lyat the tim1eof,pumpi ._n re� onsible be�pd the date above�.g N §_p
.....................
6. System Pumped By:
.......... ................
Name Vehicle License Number
AS Development Corp., d/b/a Stewart's Septic,
Service,, 518 Sol. Kimball' St., Bradford, M�A 01�8315,
.................................I.,...........
7. Location where contents were disposed:
Stewart's, Receivin^ Facilit , 20 Sol. Mill St., Bradford, MA 018315
.......................
Jen
See above
Signature of H�lauller Date
............ .................... -----------------------------
Signature of Receiving Facility(oir attach facility receipt) Date
t5form4.doc* 11/12 System Pumping Recordo Page 1 of 1
Commonwealth of Massachusetts, town of h'Orth AndoVer
................................
City/Town of No. Andover 44AR 3 20126
System Pumping Record
Form 4 LI
Partment
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 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
career-do not No. Andover MA 01
use the retur 845
n
key. City/Town State Zip Code
2. System Owner-
tab
0L
..............
Name
Address(if different from location)
-------------
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping -D a t e 2. Quantity Pumped: Gallons
3. Component- El Cesspool(s) El Septic Tank E] Tight Tank El Grease Trap
E9 Other(describe)- ...............__------------------_---------------
4. Effluent Tee Filter present? 0 Yes No If yes, was it cleaned? Ej Yes [I No
5. Observed condition of component pumped:
9 oo J, Al of this estimated
information is non-binding,, valid on,ly,at the time of um ina. Not res nsible beyond the date above.
_p..............I.---------_- .......... .............
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-
Stewart's Receiving Facility __._ So. Mill St., Bradford, MA 0183,5"'
See above
Signature of Hauler Date
---------- ------------...........--------
Signature of Receiving Facility(or attach facility recent) Date
t5form4.doc* 11112 System Pumping Record Page 1 of'l
of'�'Orth An I
Commonwealth of Massachusetts dover
Pl
z City/Town of No. Andover
System Pumping Record
:::..
MAR 3 2026
Form 4
DE P has provided this form for use by local Boards of Health. Other forms, r:abso
information must be substantially the same as that provided here. Before using this form, 11,101 1"Ll r
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
tab, 2. System Owner-
& rl-
Same rz ei'l L el,--------------
Name
------------ .......
Address(if different from location)
City/Town State Zip Code
..............
Telephone Number
B. Pumping Record
z
1. Date of Pumping Date
3. Component, Cesspool(s) [I Septic Tank El Tight Tank 0 Grease Trap
Ij
Other(describey
If yes, was it cleaned?4. Effluent Tee Filter present? Yes 0 No -1 Yes E:1 No
5. Observed condition of component pumped,
All of this estimated
Eton is non-binding., valid only'at the timeofpum_ping. N.ot roe p gnsible beyond the date above.
............
6. System Pumped By:
„j Name Vehicle License Number
IN
AS Development Corp., d/b/a Stewart's Septic
Service, 58 So. Kimball St., Bradford, MA 01835
7. Location where contents were disposed'.
101
0
Stewart's Receiving, qy Facil 20 So. Mill St., Biradford, MA01835
_
See above
Signature of Hauler Date
---------------- ------------------------
... _...._ _....__ ..�... _____.__.__ ...w._�._�.. _��.w...._...� .._..... _
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc#11/12 System Pumping Recordo Page 1 of 1
RN
Commonwealth of Massachusetts Tow,-,i G`f 49,1h Ando*r
C"Ity/Town of No. Andover
MAR 3 2026
System Pumping Record
Form 4lb
DES' has provided this form for use by local Boards of health. ether forms may be used, but the
information must be substantially the same as that provided hare. Before using this form, check with your
local Board of Health to determine the form they use.. The System lumping 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:
n the computer, .., . �.
use only the tab � � � � ,
__..___......__ _.....__.... .._..___-_____..__..__..._. ...__W.._ ______.___w.._...__._..... ___....__W.._ _..._..__.___. _._.._m_. .._.____.._.____._.�___.._._.._.._.m.w. ._....... .._. ....__.._.... _.......... .._... __.......
key to move your Address
cursor-do not No. Andover 1 45
usethe return City/Town_ _..__..._. _____.._.__..w__....._.._.._..._.__ _._ _..___..
tote.. �i_�....�
key. � �....�..._��._� �
de
2. SystemOwner-
tab
Same
_.......---
----------- -------- ................ ..__..._._____.._............. :...®_._ -------- .__..__._..__.._......._._.... ----
Iame
------------- _w.. ._._.w.. __.. ___ _.__..__.._....._._
Address(if different from location
City/Town State Z i p Code
__. ..._. _._______w__ ... ._._..._ _ .
.......
Telephone .._..._....___ .__.._. ._....__.._._... ._.__.__.
_ Number
B. Pumping Record
1. Gate of Pumping _.____.��__�_ ..�.:_._._m ::M...__..___.w._..�.____ 2. Quantity � .GaI o__ .�_m�__._.........._. ...__._.. .W__._.w..__..__..._.�__.
lat ene
. Component" El Cesspool(s) El Septic Tank Ej Tight Tank [:1 Grease Trap
Other(describe)- �:�_ �:._...
4. Effluent Tee Filter present? "des 1211111I �c If yes, was it cleaned? `des 0 No
5. Observed condition of component pumped-
A,ll of this estimated
- _ _ _ wrrFr.�. Pt rep cnable be end the date above..
information. ._! _n r_ n d n .....v l _ n l_ h e time _.. ................_�. `_..�_.�_.� .�w_.....__.. .__.�.
6. System Pum ed B y:
_.._..w.._.. ._ ___._w .................... ----------
mm_._ ____.... _ ....... _.___.__._.______._.__ __.....__.__
w�
Name Vehicle License Number
S Development Corp. d bla Stewart's Septic
Service, 5 So. Kimball St., Bradford, CIA 01835
................7. Location where contents were disposed:
terart
µ .-- ilia 2. ._So._M ill St., radf rd,...M 1 35 lac
See above
gym,
mature of Mauler Cate
.......
Signature of Receiving ._.._w..._.. �._.._..._ ......_�.__....
nature ._....___..u__._.�____-___ .._..._......._._..._.___mm_..._m.___� ._......�..._.........._.....
nog Facility(or attach facility receipt_ [date
t5form4.dcc, 11/12 System Pumping Record•Page 1 of 1
fvvvji 0 r A�O rth A n do ver,
Commonwealth of Massachusetts
AAR 3 826
City/Townd ve
System Pump*ng RecordH(-,,3jih0
7
Form 4 pc�11''ti,r1r,
EP has provided this farm 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 farm, check with your
Decal Board of Health to determine the form they use. The System Pum ing 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
key to mao� your Address w ___
cursor-do not lea. Andover C' 1 45
usethe return - _City/Town...m_�.___._._.__���._.____.._w__...._..�___.. _.___M.... .. ..__._..___._w w._._..___.�.�W _ .� State.. ......_._....m__._...._.. .a.�.__._.ww__.__.._._____.___..._....___.
2. System Owner:
Same .......................... ,
_.__..
Name
rear) ............ .......................... ...........
Address cif different
�......._._. ......._....__. _....._._........._.m_ ..�.�__._. ant from location)
City/TownState Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping _...._�_ �_._ _..._.._.. .�.................._._. _ �_. �__._._.. 2. Quantity a n t i ty P u m ed: �.__ ___w. �.. ...�..
Coate Gallons
3. Component: Cesspool(s) El Septic`dank El Tight Tank El Crease Trap
VOA-5e
th (describe): �_.__________._._. __.____.. .._.._.. .___.....__________._________ . ..... ....__...._....._...._....._.. __._...__..______w.____w._._._..___.... __.___....... .___.......
4. Effluent Tee Filter present' `des 2 No If yes, was it cleaned? "es El No
5. Observed condition of component pumped:
All of this estimated
information is non-bindin , valid only at the time of um in Not responsible beyond the date a.boVe_..____.
_ ___..._._._..... ........._........._...._..__.__...._......_ _.._ .. .__.. . ...__.__. _.._.time.,of l _... _._.. ..._..�_._ __.._.w.__
. System Pumped y:
/-�-0"-So-r...........
.w_.._.._._ M... .._._.._....--._____ _. ._... . ......_ _...._.. _._ _.......m.....w..._._ _. . ...
Name Vehicle License lumber
S Development Cora db/a Stewart"s Septic
Service 5 So. Kimball St. Bradford 01835
._ ......_. t_._.__....____._.....____ _______ .. ._ _.._....._..__.._ _.. ......._..._.._
7. Location an where contents were disposed:
Stewart's eceivin faciR�__,20,
So._ Dill St., Bradford, I C 1 5_....._........ . ..... ___._.w_._w__.__..._.w_______._............. _.�..__._.__..._.._.._.._...........
_...._.__ __...�...._ �_ _.._
Is � above
Signature of Hauler Cate
4facility
Signature of innFacility r at attach rei C _.......�.
t5form4.doc,o 11/12 System Pumping Record Page e 1 of 1
Commonwealth of Massachusetts
kA R
City/Town of No. Andover 2026
System Pumping Record 'VIE
..........
Form 4 P
Me t
/7
DE P has provided this form for use by local Boards of Health. Other forms may be used, but the
information mu st 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. Faci l ity I nformation
Important:When
filling out forms 1 System Location-
on the computer,
use onily the tab 1 (0
--------- .. ......
key to move your Address
cursor-do not No. Andover MA 01845,
use the return -----------
key. City/Town State Zip Code
2. System Owner-
IA6 1007)
Same
Name
few
..................
Address(if different from location)
City/'Town State Zip Code
Telephone Number
B. m pA ng Record
(3 ')---1- -006
1. Date of Pumping D at e --- 2. Quantity Pumped'. -G a 11 o ns
3. Component- Cesspool(s) 0 Septic Tank E] Tight Tank Grease Trap
..........
EROther(describe)- 9 el
4. Effluent Tee Filter present? [I Yes, No If yes, was it cleaned? E] Yes E] No
5. Observed condition of component pumped:
2 00 All of this estimated
-!n1fo,r,m,atioP--i.s-n.99,7-bi..n.d.ins valid o'n.1y.,,,at the tinny of mpin Not responsible b ond the date above.p
..........
6. System Pumped By:
Name Vehicle License Number
AS Development Corp. d/b/a Stewart's Septic
Service, 58 S . Kimball St., Bradford, MA 01835
7. Locat n where contents were,disposed-
Sty wart's Receiving.facilit 20 S . Mill St., Bradford, MA 01835
144 01,S C 11 :To
See above
Signature of Hauler Date
Signature,of Receiving Facility(or attach fac ility receipt) Date
t5form4.doc*11/12 System Pumping Record Page 1 of 1
o
�� Commonwealth of Massachusetts 0
Ci /Town of .No.Andover
R4
System Pu mping Record
Form 4
- z
DEP has provided this form for use by local �3oards of Health. Other forms may b6 1@ft t the
information must be substantially the same as that provided here. Before using this form h your
local Board of Health to determine the form they use. The System Pumping Record rn t be sub *tted to
us S9
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
use the return
Ivey. Cityf'rown State Zip Code
2. System Owner:
Name
Address(if different from location)
No.Andover MA
City/Town State Zi p Code
Telephone Number
*'I.......... tcor
2. Quantity Purnped*
1. Date of Pumping oat
3. Component: Cesspool(s) S Tight Tank _..�_.
Grease Trap
1 ep�tic Tank
Other h s
Other(describe)-
4. Effluent Tee Filter present? Yes 0-_,--No If yes, was it cleaned? Yes No
5. Observed condition of component pumped,
6. System Pumped By:
Name Ve'Hicie License Number,
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
V; �
20 So. ill St.,Bradford,MA
de
\j
Signature of Hauler Date
§ nature of Receiving Facility(or attach facility receipt) Date
_9
t5form4.doco 11/12 System Pumping Record•Page 1 of 1
Of A/n r
Commonwealth o
City/Town
�..ww
p`
..r
...
iye
System Pumin r
Form
provided this for r use local Boards o Health.. Other forms used, but the t
are rm tion t u t nti ll thr s th�r t rows ' r ire th l r , c with r
local Board of Healthdetermine form they use. The System Pumping Record
the local Board of Health or other approving authority within, 14 days from the a i
accordancewith I0 CIVIR 15.3511.
A. Facility Information
Important: hers
filling out forms 1 System Location*
o the computer" Z, .,µ
use only the to
key to move your Address
cursor o not Andover MAuse the return � w...�._�_� -
�ey, City/Town � State Zip Cod
2l. System Owner:
t
Name
.................................... .................................... ........................ ........................................... ................................................
Address it differnt from _.._.cation_m..�_._ �_
City/Town
�.� �Stte._�-- ..Zip�Code
Telephone
Number
B1.1 P,u�mpoing Record
. Date of Pumping _...a e1-111._.m__..m _.,=--___ . Quantity Pumped: G 11 a 1m_- .
3.
E]
El
ap
r n s--- of t-ip- r _ Ti t Teak r Tr
ooe r(describe),
4.
EffluentTee Filter resent? o If yes, was it cleaned? Yes No
. Observed dition of m� oinentpumped:
All of this th t
information_ is....n..on-d_pn i_s -valid- o...n_ l .. t the time_ of_ _l . m.mmom_f...r_ i l 'ego t . t ._.... ._..._..
61. System
/#0 � ,
Name Vehicle Li,cen�se Number
J&S Development Corp. d/b/a Stew art's Septic
Service,, 58 S� . Kimball St.I Bradford", MA 01118315
Location where Conte is were disposed:
w. _t.e a "S �
�. R_ . lc .F....__. ilrt. . 20 Sol. Mrll St.,__. r_d. rd
:
See,above
_ u
Signature of Hauler [date
Signature of Receivinlg�-- _ y attach facility r ei it, Date�
t5folrm4.doc• /12 System Pumping Record.Page 1 of'
�u
Of
Commonwealth of' Mass,achIusetts /7,YO
City/TownRA
:w": 414 71 System Plumpling Recor�d Y 2026
Mo "
De
DE,P has provided i form for use local Boar used, bu
nforr r s i � h r i r . for ire i for , c littyou
local Board of Healthi to determine the form they use. The System Pumping rsubmitted to
the local Boardl r other appir,oviing authoritywithin 14 daysfrom ire i
accord'ance1 .
A,. Facility Information
Important-Whien
filling outforms in
on the computer,
ter,
M
key to move your Address
cursor-do not N o. Andover
usethe return _ ..... U..v,.. _...__.._...__.n.__........ .......... ___.,_..... .........._.__ ...... --_m..... ._......._
key. City/Town State Zip Code
tab 2. System r:
Same
_.__..e-....._
Name
,address(if different from,l cap N ru
� �� _.- _m_.._. .. ."_ _.. �.. m........ ......�. .. _... _--,.._�� . ..._m.._ . ..a� .� _... ....... ..........
State Zip Code
_.. ... .... ........ .......... ............
Telephone Nu r
B.1 P!ulmpoing Record
1 Date u
.. ..._ ...:...._ _� _m._mm .mQuantity ---------------
Daite
Gallons
Tight,31., Component- Cessiplool(s,) E] Septic Tank Ej ank rease Trap
Otherr _ ..................................----................._" _......._ . .
µ..
4. Effluent Tee
Filter r I
5. Observed condition of componenta w
information is r _w�.��_ � � ������ r�� a the time �� �r�� . Note rase nsible b and �e date above.,
.�...._......w........ .._...�.. .� __........�.m...._.. ....�.. ...
-.M�.. ......___w.....�..,. �......,-_.�_....._....�_ ..
6. System Plumped By.
Name Vehicle License,Nu bar
Ji&S DevelopmentCorp. 11 ii
Service, 518,
Kimball '., Bradford! 11
.............. ... __. m_...._..............................µ.. _.... a.,.u'
S ewar°s, Recei it^ Facli, 2 Sp Mill S , Bradford, MA35 it
See above
Date
_...
Signature of Receiving Facility(or attach facility receipt) �e
5 rr u #1'1/12 System Puumpiinig Record Paige 1 of 1
IY80111M Of No�h Andover
Commonwealth of Massachusetts
MAR 3 20
City/Town of No. Andover 26
System Pumping Record
lit 4 Department
Form Vkou
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 Cli 15.3151.
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 145
use the return A--
key. City/Town State Zip Code
2. System Owner:
Same
Name
Jill
A---, ----------
Address if different from location)
..........
City/Town State Zip Code
----------------...... ------------
Telephone NuMber
Pumping Record "lop
f�>
-4-0..........
1. Date of Pumping Date 2. Quantity Pumped. Gallons
3. Component'. Cesspool(s) El Septic Tank El Tight Tank 12jr(irease Trap
Other(describe): ------------------- ------
4,. Effluent Tee Filter present? [I Yes 'o If yes, was it cleaned? El Yes
5. Observed condition of component^urnpedl.-
7
All of this, estimated
information is no valid only at the time of ible.be ad' the date above.
__pumping. Not,re§p
6. System Pumped By.-
......................
Name r 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 Receiving'.Facilit 20 So., Mill St., Bradford, MA 01835,
See above
Si nature o au er Date
........................
Signature of Receiving Facility(or attach facility receipt) Date
t5forrn4.doc,*11/12 System Pumping Record Page 1 of 1
own Of Not Andover
Commonwealth of' Massachusetts
MIAR 13 2026
Q City/Town of' Nol.1 An�dover
System Pumping Record
H"r e, P PI, m e n
Fom 4
DEP h�as provided this,form;, for use by local', Boards of HIealth. Other for may be used, bul:t the
information must be substantially the, sarne as that provided here. Before using this,form, check with youir
locall rd of It to determine the form they use. 'The System, Purnping Record must be submitted to,
the, local Board of Hleal'th or other approving authority,within 14 days from the plumping date in
accordance with 3101 CIVIR 15-35,1.
A. Facillity lnfolrmaltion�
Important-When
filling ou�t forrins 1 System Location:
on the computer,
use only the tab
...... .......... ............. ...................................... ............
key,to move your Address
cursor-do not No. Andover MA 0 18,45
use the return ...................... —------ ...........................
key. City/Town State Zip Code
2. System Owner-
-21
Same
............................... ..................... ---------------.........
Name
/Van
.....................------ ........... ................ ............... ............... ......... .........
Address(if'differerat from locati,oln)
......................... ............. ........ ............------ ......................................
City/Town State Zip Code
--------.......................................... .............
Telephone Number
B, Pumping Relcord
I. Date of Pumping ............ 2., Quantity Pumped., 1-o o di
Date Giall.ons
3. Component* Ceis,s,pool(s) Septic Tank, E:1 T'ight Tank 0 Grease Trap
Other(describle), ............... ...........................................
4. Effluent Tee Filliter present? El Yes �] No If yes,l was it cleaned? E] Yes 0 No
5. Observed condition of It pumped,
0 All of'this, estimated
infor�miation is, non-bindin , valid only at thetime of um ing. Not res onsible.bleyond the date ablove�.
...........
6. System 'Pumped By-
Of
...............
Name Veh�icle License Number
AS Development Corp. d/b/a Stewar�t,s Septic,
Service,, 58, Sioi. Kimball St., Bradford', MA 01183,51
............ .................................. ............
7'. Location where contents were di�s,ploseid-
Stewartill s Receiving_ ci��ity,_.20 Sol. Mill Sit., Bradfoird, MA 0!1835
............ ........ ...... ................. ..............
.............__._ _
See above
Signature of'Hauler to
................ ............ ................... .........
Signature of Receiving Facility(or,attach facility receipt) Date
t5fbr,m,4.doics 11/12 Siys,tem Pumping Recordo Page 1 of I
Commonwealths of Massachusetts TO� VV'9 Cf NOM Andover
City/Town of No Andover
MAR
System Pumping Record 3 2026
Form 4
H
I eU�
DEP has provided thi& form for use by local Boards of Health. Other,forms may e vs4p),`
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health �,,-,o determine the form they use. The System Pumping Record must be submitted to
the local Board of He Ith or other approving authority within 14 days from the pumping date in
accordance with 310 CIVIR 15.351.
A. Facilit 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. Cityfrown State Zip Code
.V
2 System Owner-
tab Q
Name
Address(if di� __._.__..__._.v______ ____._., .._.__ .__..�. _
fferent from location)
No.Andover MA
City/Tolwn State Zip Code
Telephone Number
B,. Pum ping Record A01
02/ w 0ao
1. Date of Pumping oat 2. Quantity Pumped. Gallons
3. Component- E] Cesspool(s) Septic Tank Tight Tank Grease Trap
9 11P
Other(describe):
4. Effluent Tee Filter present? El Yes X__ No If yes, was it cleaned? LL Yes No
5. Observed condition of component pumped-
let
6. System Pumped By"
Name Vehicle License Number
Stewart's S ic,58 So Kimball St. , Bradford,MA
Company
7. Location where coontents were disposed-.
20 SoMill St.,Bradford,MA
'A
Signature of Hauler Date
§ nature of Receiving Facility for attach facility receipt) Date
Fg
t5form4.doc#11/12 System Pumping Record Page 1 of 1
Commonwealth of Massachusetts Town of Not Andover
City/Town of No. A dove,,
MAR
- 3 2026
System Pumping Record
Form 4
Health Department
DE P 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 data in
accordance with 310 CAR 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
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. Gallons
3. Component- Cesspool(s) Septic Tank Tight Tank Grease Trap
of her(describe):
4. Effluent Tee Filter present? 0 Yes 9A*1010/ If yes, was it cleaned' 'es No
5. Observed condition of component pumped-
goo (L All of this estimated
information is non-binding vali"nly,at the time of s and the date above.
_p_mM
6. System um ed 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-
Stewart's Receivin Facility,_20 So. Mill St., Bradford, MA 01835
9----------- -------
See above
J, Mauler Date
................................
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc,11/12 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts Town of NMh Andover
C"Ity/Town of No. Andover
rm: m > -- 3 2026
MAR
System Pumping Record
Af Form
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 farm, check with your
local Board of health to determine the farm 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 a CMR 15.351.
A. Facility Information
Important When
filling out forms 1. System location:
can the computer,
__...... _.._.._......____M._.. ._.__.._..._..._. .._._..e.. . .°.
use only the tab
key to rrrcve your Address _.____.__ ..a..._.. ....._.____.._....__�..___._�.._..._._.�.._._.�_�_.�._.m...�. ............
cursor_do not No. Andover ILIA 1 45
use the return _ _._......_ _w.. _.._.. ......._ __.
key,
c�it /�'r`cr�n �.__._,__________W_______._����.__..____..�._�_._�.._.__.__.____.._�..___n____..____......_....._...__.._......w State Zip
_�.____ �_�.____�..�.__..._____.�__.__._ �� � _.._..__....__ ..v.______
de
t
. System Owner:
Same_..__..__.w. ..............__.. __.__w .. ........
Marne
_ _.__......_.... _. _ _................... w.__...._r ._..._.._.....m ... m....._...._...._.._ ......_.. ...__.._..w__,.._.... __._.__
Address(if different from location)
City/Town State Zip Code
Telepho�ne Number
B. Pumping Record
17 67
1. Date of Pumping -Da-t e____._.. _ _ _._ . Quantity Pumped: ..t�..._el l c......._..._....ns... ....._.__.__..... ......... _ _........
at
3. component: El c esspool(s) 0 Septic Tank El Tight Tank 0 grease Trap
E2/10ther(describe).
4. Effluent Tee Filter present? 0 Yes NAO If yes, was it cleaned? El Yes El No
5. Observed condition of component pumped:
6't:?C)o<4 All of this estimated
information is non bindin , valid at the time of um rn . blot responsiblebeyqTjd the date above.____.___._._ � _.__.._... _M...M___._MM ._..._..._.._. .........n.....__.
6. System PumpedLl
.__........
Larne 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
Stewart's Mace' in Facilit, 20 So. ill `t., Bradford, ILIA 1 35
See above
cf r bate
Signature of Receiving Facility(or attach facility receipt) Date
t fcrrn4.dcc•11/12 System Pumping Record.Page 1 of 1