HomeMy WebLinkAboutMarch 2026 Bake and Joy - Septic Pumping Slip - 351 WILLOW STREET 3/3/2026 Commonwealth of Massachusetts Town of No�th Andover
. __ _wF.._ City/Town of No. Andove- == r
System Pumping Record APR 7 2026
Form 4
Ib
DEP has provided this form for use by local Boards of Health. Other forn4djaWt6 LQQpadWent
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 c omputer,
use only the tab 0 tj
--------------- ----------- ............................. ......-------..................
key to move your Address
cursor-do not No. Andover MA 01845
use the return ...... ..........
key. City/Town State Zip Code
M6
2. System Owner:
Same
....................... ...................................................... ............... .............
Name
................................ ................... .......... ----____--------- ................ .................. ........
Address(if different from location)
City/'Town State Zip Code
................
__.�. _W______.__.. ._.___ ......_..._.._.�_.._.......__...__...n...._....._..� _..._._..
Telephone Number
B. Pumping Kecord
I Date of Pumping Date -- 2. Quantity Pumped: Gallons
3. Component- Cesspool(s) 0 Septic Tank E] Tight Tank 0 Grease Trap
S' lo loot
Other,(describe). ------------------------ ------
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? 0 Yes Ej No
5. Observed condition of component pumped:
0 0 All of this estimated
information is non-bindingvalid on at the time of onsible be rid the date above.
...... --- Not re§p
..............
6. System Pumped By:
A-
.................
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 Facillt'�/,,...20 So. Mill St., Bradford, MA 01..........
j 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
Commonwealth of Massachusetts Town of tqOrth Ando
Ve
Cif /Town of N .Adver
APR 2026
System Pumping Record
Form 4
Health
I
DE P has provided this for for use by local Boards of Health. Other forms may bw?44
information must be substantially the same as that provided here. Before using this form, check with your
Iota l 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
cursor-do not
use the return -------
key. City/Town State Zip Code
2. System Owner- ......
Vtab
Q
1`vlamo
No.Andover MA
City/Town Mato---l-1- Zip-Co.de ------
Telephone Number
B. Pumping Record
P-
2
1. Date of Pumping 2. Quantity Pump ed.
3. Component- Cesspool(s) Septic Tank Tight Tank j Grease Trap
Other(descr,ibe)*
4. Effluent Tee Filter,present? Yes )_.�..� No If yesl was it cleaned? Yes No
5. Observed condition of component pumped-
6. System Pumped By-
Z�j 0�Oyj
...Nam .......e Vehicle License Number
Se war-t-'-s Sufic58SoKimball St radfbrMd6mPanyB
7. A
Location where contents,were disposed:
20 So Mill St.,Bradford,
Signature of Hauler Date
t i—gn a—tu-r-e-o f-,-R 6-6e-,'v-i'n'6-Docility—(o r aft c-h--f-a-c-i J,i-ty—receipts ......
t5form4.doc,*11/12 System Pumping Record Page 1 of 1
Commonwealth, of Massachusetts TO Wn of NOrth 4ndover
City/Town of No.
APR 7 2026
M System Pumplong Re r
6
FormHealth L)e,,,,
DEP has provided this form for use by, local Boards of health. Other forms may be used, dI 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 rust be submitted t
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,
useonly the tab ... ........._.._�...................__..._..__. _.._....... _._........ _..__�..._� _�......w_. _.......w....... �
�. . __._.._._._.__......� _..._..w_ W_._._..... .�... ._.. _ ....._. .._.... ....�.�..... .w. .......... ._ �.�.._...
key to move your Address
cursor do not No. Andover MA 01 845
use the return City/Town City/Town
State Zip Code
_.
to
. System Owner-
Same,
Name
Address if different from location)
Mate _Zip
Code
Telephone Number
B. Pumping Record
1. Date of Pumping _........... __.�___.w.__._...... 2. QuantityPumped: �.... ....._. _..__.._..._..._.. _.._w
Date
3. Component- Cesspool(s) El Septic Tank Fight Tank 0 Grease`trap
2eo Other(describe)-
4. .__..._ .____..._.. a.. . _. __._..___.._. ......... _... ...__. ...._..._. ___._. _._.
Effluent Tee Filter present? Yes If yes, was it cleaned? Yes No
. Observed co iti n of component onent pumped:
(Soo,. All of this estimate
__... time, f. um n of res Bible CC nd the date above.
nnbar .� M. . v�l.id.. nl.. t.t.h_. ..... ..__._. __.........._ �... ................._.. .. ............._ �.... _......._ ._._M...__Mm.. _..
6. System Dumped �.
0000
Vehicle License Number
S Development Corp. d b a Sty art's Septic
Service,, 58 So. Kimball St., Bradford, MA 01835
. Location where contents were d spore&
Sty art's.. ecei in ...Facilit ..= C S ..ill St.., radford,...e...._ 01 �'�� _...........�...._....�40000-WI—ce-, f
See above
Signature f..N�Nau Date
Nor........ ....._...._..__.__.._w._._._._._. ....�...__ ....w_ .._._...._........�_... . ....�......._._.... .µ......__.� ......._...............__u._.._�_w__--.___...�
Signature Receiving
Facility or attach facility
receipt)
.�.... Date
.
t5fcrm4.doc*11/12 System Pumping Record Page 1 of 1
Commonwealth of Massachusetts Town Of NOrth Andov
...........
City/Town of No. Andover am#
APR
72026
System Pumpi ng Record
Form 4
At- Health D,,50
Not
DEP has provided this for for use by local Boards of Health. Other forms may be useg 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: 001,
on the computer, 1)"100
use only the tab -------
........ Vy'
key to move your Address
cursor-do not No. Andover MA 01845
use the return .�..�.._.. .......�.._.._..._ ___,...... .._.W rvrvw.
key. City/Town State Zip Code
2. System Owner-
VQ
Same
Name,
MW
.......................
Address if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
13"'6"
1. Date of Pumping D-a te 2. Quantity Pumped- ...Gallon.-1 _._--_.-.,.._ ....___--.-- --"-.
3. Component- Cesspool(s) [I Septic Tank E] Tight Tank El Grease Trap
49 4/p 44
[I Other(describe).
4. Effluent Tee Filter present? El Yes No If yes,, was it cleaned? Yes No
5. Observed con I ion of corgi poen neat pumped-
&—,40'ev : All of this estimated
information is non-binding.,valid oral at the time,,.of um ire g. loot responsible beyond the date above.
6., System Pumped By:
<j
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 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*11/12 System Pumping Record Page 1 of 1
Commonwealth of Massachusetts
Town of IVOrth A dover
City/Town of No. Andover
System Pumping Record APR 7 2026
Form 4
Heeits
DE P has provided this form for use by local Boards of Health. Other forms m
PR c A' $t vi�th your
information must be substantially the same as that provided here. Before using this form,
Decal 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 plumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location-
on the computer,
use only the tab
.......... .......................... ...................I
key to move your Address
cursor-do not No. Andover MA 01845
use the return ...... .............
key. City/Town State Zip Code
2. System Owner:
t8b 4
Same it �'Jlo V
Name
Address If different from location)
City/T own State Zip Code
..........
Telephone Number
B. Pumping Record
5D Z)
1. Date of Plumping 2. Quantity Pumped-
Date Gallons
3. Component- Cesspool(s) Septic Tank 0 Tight Tank El Grease Trap
12/Other,(describe)* ---filo - --+— -.1.,,."-.- -11...,,�.-".,-.-,,ry- .ry.-.... ..................
4. Effluent Tee Filter present? E:1 Yes 2/N o If yes, was it cleaned? 0 Yes El No
5. Observed condition of component purnped*
111111111111111141S IL)ebc All of this estimated
information is non-�bind i ng,,_va lid onl t the time ofp d the date above.
__q_ p._i,ng. Not responsible be
6. System Pumped By-
I -
Name Vehicle L icense 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's Receiving F'acilit 20 So. Mill St., Bradford, MA 01835
See above
.....—--------
ture of Hauler Dat .- --e
.......... ........ -------
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.docs 11/12 System Pumping Record Page 1 of 1
Town Of Nofth Andovel
Commonwealth of M assach usettmm w
City/Town of N .A dover
A PR 7 2026
System Pump"Ing Record
Form 4
Healfl.,
03pa,
DE P has provided this for for use by lc cai Boards of Health. Other forms may be usedl,
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. S stem 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
V Q 2. System Owner:
tab
Name
Mon:x
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Number
PuMp'1in'g`1Reco'rd
.0e
1. Date of Pumping 2. Quantity Pumped-
Date Gallons
3. Component: j Cesspool(s) Septic Tank C.... ig grease Trap
Ti ht Tank
_�ther(describe):
4. Effluent Tee Filter present? ['] Yes G 'a' If yes) was it cleaned? Yes No
5. Observed condition of component purnped-
........... .......
6. SysteM Pumped By-
ro
Vehicle License Number
Step,:art's Sep ic 58 So KiballSt , Bradford,Mto —a n__y
7. Location where contents were dispose d-
20 So. ill St.,BradfordMA
7
100,
Date
nature of Receiving Facility(or attach facility receipt) Date
t5fo�rm4.doco 11/12 System Pumping Record o Page 1 of 1
rcCommonwealth of Massachusetts Town of NOrth An
sw City/Town . Andover
APR 7 20
System Pumping Record
SN'
Form 4
He,91th
DEP has provided this fora for use by local Boards of Health. Other forms may be us,eA qild�
information must be substantially the same as that provided here. Before using this farm, check with your
local Beard of Health to determine the form they use. The System Pumping Record must be submitted to
the local Beard 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, 35-1
se only tl tab :._. ..__ .._._.. __._... "_.0 " ____.
key to move year Address
cursor-do not No. Andover 01845
usethereturn City/Town/� __�..__.��________ __... _.µ.___.__._m.__.__..M..._.M..._...._ .._.n.....__� __.__...__.__.._._..__._-___....w .._ . __ .__._____.._.._..._ _____.. _w...._.._w.__.. _..__ _..__________ �_...........__._... _..__..�___ ...____._..
key. y wn State ,dip Code
Uh 2. System Owner:
Samea/,,�e
_._..__._ _._._.._ _..m..._._..w. ................ -------- ............
Name
Address(if different from location)
.._._.......
M..._.___
City/Town State ;dip Code
Telephone Number
B. Pumping Record
w
3
1. Date of Pumping _. �w___._ _____ _____.____..___.__..�_......._ 2. Quantity Pumped _ _:._.__�
Data gallons
3. Component: c esspool(sSeptic Tank Fight Tank crease Trap
f7l Other(describe): _____...._._....___._... __... _.. .___..____...__ W___._._w_._____..._.__.._ _.... _.._..___.._...... _ __.....___
)CIJ
4. Effluent Tee Filter present? 'es 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 umpmiµn . Not responsible be
___._..... .m.__._m..M.. MWM..a_.. .._w._.. .. ._ a�_d�.t_-_he date...above._
.._
. System Pumped y.
Vehicle License Cumber
S Development Corp. d/b/a Stewart's Septic
Service, 58 So. Kimball St., Bradford, MA 01835
. Location where contents were disposed:
Stewart's Receiving l~ `lcty...�20._.So.._Gill St., Bradford, MA 01835
AV
See above
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Data
t5form4.doc# 1 /12 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts Town of NO*Andover
T f No. Andover APR 7 C1
2026
System Pumping Record
h
Form 4 Heaft ,,, De,,,,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 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,
X Fac i l ity I nformation
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
OQ 2. System Owner-
Same IN
----------- w.
Name
............- ------ ------------- ------
Address(if different from location)
City "tarn State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped-
Date Gad ns
3. Component. E] Cesspool(s) Septic Tank Tight Tank Grease Trap
ll�
Other (describe). ..... ................ .........._._.............
4. Effluent Tee Filter present? [] Yes No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
All of this estimated
information is non-bindin valid on at the time of t s onsible be_pur�ng, No re p_ end the date above
6. System Pumped By-
/� a ^
.............
Name Vehicle License Number
J&S Development Corp. d/b/a Ste art" Septic
Service, 58 So. Kimball St., Bradford, MA 01835
7. Location where contents were disposed:
Stewart's Receivin Facilit. 2,0 So. Mill St., Bradford, MA 01835
g- -Y
cry) 0 Y�e S See above
............ ...... ...........
Signature of Hauler Date
.............................. ...........
Signature of Receiving Facility or attach facility receipt) Date
t5form4.dcc* 11/12 System Pumping Record Page 1 of 1
Commonwealth of eased owls To W frj; 16dover
City/Town of No.Andover
APR 7
System Pumplang Record
026,
Form 4
Heat'
DEP has provided this,for for use by local 3oards of Health. Other formstka �t
information must be substantially the same a is that provided here. Before using this form, chec 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 L'0111/ -.0)
key to move your
cursor-do noit
use the return ...... ..........
key. City/'Town State Zip Code
2. System Owner-
j"me
MIMI
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Number
Am
B. Pumping Record
1. to of Pumping Date 2. Quantity Pumped. Gallons
I _3. Component- Cesspool Septic Tank Tight(s) Tank 1 Grease Trap
�' ) /
ither describe . 4 i/
-------
4. Effluent Tee Filter present? l. __J_] Y -es No If yes, was it cleaned? Yes No
5. Observed condition of component pump ed.
6. System Pumped By-
Name Vehicle License Number
Steiwa ri
tic
58 So Kirinhall St. , Bradfo rd.,MA
7. Location where contents were disposed-.
20 Se.Mill St.,Bradford,MA
J 7--
in"
t-i-g--r--at-u-r ii of—M—e-c-e-,i-v"-i,n__g", F",-a-c-ii_1'i ty(_o_—ra-tt'a--c'_h,-_f",a`c,_i`1_i,t_y_"-re'-,l e-_ip_t), D—ate
—
t5form4idoc-11/12 System Pumping Record-Page 1 of 1
TO
Commonwealth of Massachusetts Wn IVOrth Andover
City/Town of No. Andover
APR
2026
System Pumping Record
Form 4
Af
ea;t
DEP has provided this for for use by local Boards of Health. Other forms may b e
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 r. _3
key to move your Address
cursor-do not No., Andover MA ( 1845
use the return
key. City State Zip Code
W 2. System Owner:
Same
Name
Address if different from location)
..........
City/Town State Zip Code
Telephone Number
B. Pumping Record
Z6 d ed
1. Date of Pumping Da I te 2. Quantity Pumped: Gallons
3. Component: El Cesspool(s) EI Septic and El Tight Tank [I Grease Trap
10* 4�g 7 /<
04 0 t*t 44" ...........
ether(describe)-
4. Effluent Tee Filter present? 0 Yes a?<0 If yes, was it cleaned? [I Yes El No
5. Observed condition of component pumped-,
All of this estimated
information is non-bindi g m um 'i in�g e n ,,,valid only,at the time Not r sponsible beyond the date above.,
6. System Pumped By:
ZT^e,� ......................
..................
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:
.Stelwa,rt's.-Receiv.t.n,T,,Fa.cility, 20 So. Mill St., Bradford, MA 01835
........... ........................__........-------
,3
&e,f See above
ignatur of Hauler Date
........... ......--------------
Signature of Receiving Facility(or attach facility receipt) Date
t5f err 4,doc*11/12 System Pumping Record#Page 1 of 1
Town of No�, ,h Andover
Commonwealth of Massachusetts
EE' APR - 7 Z026
City/Town of No. Andover
System P umping Reco rd
-partment
Form 4 Health Dc
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 date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1 System Location-
on the computer,
�w
use only the tab 36-1
key to move your Address
cursor-do not No. Andover MA 01845
use the return ............................... ..........
key, City/Town State Zip Code
I ,
2. System Owner:
W
Same J'cl
-----------------------
Name
Address if different from location)
City/Town;: State Zip Code
Telephone Number
B."I"P'umping Kecord
1. Date of Pumping -D I a I te 2. Quantity Pumped- Gallons
3, Component: El Cesspool(s) E] Septic Tank El Tight Tank El Grease Trap
----------------- .........
5�KOther(describe): -1-1-111--a/0- 1. ___. #i��t
4. Effluent Tee Filter present? El Yes j4o,00�No If yes, was it cleaned? Yes [:1 No
5. Observed condition of component pumped:
All of this estimated
information is non-bin,di,ng,, valid onl t theWme of in Not r onsible beyond the date above.
6. System Pu,mped 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 Re *vi.na Facilit 20 So. Mill St., Bradford, MA 01835
eo"
See above
r o Hauler 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 Nc�u'i Andover
City/Town of No. Andover
System P u mpi ng Record
APR 7 2026
Form 4,
1 1b
DEP has provided this for for use by local Boards of Health. OthWWW1nR(bP&4MQVJje
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 umping date in
accordance With 310 CMR 15.351.
Facility Information
Important:When
filling out forms 1. System Location-
on the com�puter,
use only the tab
key to move your Address
cursor-do not
use No. Andover ............. 1845
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: Ga I I-I-o 11 ns
3. Component: Cesspool(s) El Septic Tank E:1 Tight Tank F-1 Grease Trap
[2e'Other(describe): ............
4. Effluent Tee Filter present? E] Yes 2'000NOo If yes, was it cleaned? Yes No
5. Observed condition of component pumped.-
-6/ All of this estimated
information is non bind n_g.,, valid ora
l at the me pu in.of m Not re" nsible b rid the date above.
....................... p
6. System Pumped By:
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart I s Septic
Service, 58 So. Kimball St., Bradford, MA 01835
7. Location where contents were disposed*
Stewart's Receiving Facilit 2,0 So. Mill St., Bradford, MA 01835
See above
it auler Date
----------- .......... .........................
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc#11/12 System Pumping Record Page 1 of 1
ox
Town c Not Andover
Commonwealth of Massachusetts
City/Town of No. Andover
APR - 7 2026
System Pumping Record
1,02
Form 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 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 forms 1. System Location-
on
the computer,
�... ..
use only the tab
key to move your Address
cursor-do not No. Andover MA 0184,5
use the return
key. City/Town State Zip Code
__....... ww�........
Sams.... .........................._....._.. .._._..... _....._..... _._..._ .:._..µ._... N.......N ......................... ...... _........_... m._m.....__.._.._._._.___u_
Name
faun
Address(if different from location
CIt ........._. .._..____._.........M__ _._.___._......._. _..................... .............._ __ .._
Mate Zip Co
_.._................w.
Telephone Number
B,, Pumping Record
. Date of Pumping �� �. .. _....�... �.____�._.�..w__....__.�.__. 2. Quantity, Pumped. _..._. .--____.�._............
._�.._�
Date Gallons
3. Component: Cesspool(s) El Septic Tank 0 Tight Tank Grease Trap
Other �� r� � : ...a._....... ....�..... __..__.. _.-- .. �� _ _. ... .._..... __.....�.. ..__.
. Effluent Tee Filter resent" Yes No If yes, was it cleaned? 0 Yes E:1 No
5�. Observed condition of component pumped:
06a All of this estimated
__.v..__ ... _ ..... ..a� above...
.-
__pumping.is non bindin valid only at the time.,of�� .. . .! .��..w.. t..r��.�.� n�tbl�� be .. .n.d..t e date....�... ... _.e....-
_-.-___ __.._.._._ _m........ .._...._�.......w............ �._�... ..___..._._.�.. __._.. ._
. System lumped
Name�.�� ...M hide License Number
&S Development Corp. d b a Stewart's Sept,ic�
���ice,......58_.So."_._.Kimball...St , Bradford, :......._ 35�.��.�.
i
7'. Location where contents were disposed,
Stewart's Receiving,Faci,litv, 20 So. Mill St., Bradford, MA 01835
_.._... ............_._ _.ww..M.___-__w __ �...w..._.. ..._...._.............. __... _w_..w
See above
Signature of Hauler Date
...................---
Signature of Receiving Facility(or attach facility receipt) late
t5f rrr . System Pumping Record Paige of 1
Commonwealth of Massachusetts Town of Nofth Andover
C dover
APR -ol 2026
System Pumping Record
Form 4
DEP has provided this for for use by local Boards of Health. Othlirfia6QUpiRAIMIteat
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 Pun in Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
acc ordance with 310 (*.**MR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location,
on the computer,
use only the tab � ..._._. _.. .. � _._._..._.....,..�ww. ..._..m _ .�.. _.w.._.._____�_ ..__._.. ... ,�_. .
&
key to move your Address
_ _ .�
cursor-do not
use the return
key. City/Town State Zip Code
2. System Owner-
'tob
VQ
_T__
Name
Address(if different frcm location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
006
1. Date of Pumping 2 Quantity Pumped*
Date . Gallons
3. Component* Cesspool(s) Septic Tank Tight Tank
_J Grease Trap
Other(describe)-
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes No
5. Observed condition of cornponent pumped,
6. System Pumped By:
Name Vehicle License Number
Stewart's S tic 58 So Kimball St..._, Bradford MA
d-o,-m--p—an y-
w.
7. Loc ation where contents were disposed,
20 So. ill St.,BradfordMA
� e Signature V Hauler Eat
ignature of Receiving Facility(or attach facility receipt) Date
t5form4.doc#11/12 System Pumping Record#Page 1 of 1
Commonwealth of Massachusetts Town of Nofth Andover
City/Town of No. Andover
fA APR 7 026
System Pumping Record
Nor Form 4 artment
Health
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, 2
use only the tab :?�5 -------
............. ----------- ..............
key to more your Address
cursor-do not No.use the return Andover MA 01845
-------...........
key. City/Town State Zip Code
2. System Owner: A
tab
VQ
Same
Name
Run
Address(if different from location)
.................. ...............
City/Town State Zip Code
Telephone Number
B. Pumping Record
7D e?'-7
1 Date of Pumpi ng 2. Quantity Plumped.
Data Gallons,
3. Component.- E:1 Cesspool(s) E:1 Septic Tank El Tight Tank El Grease Trap
t
Other(describe). .........................
4. Effluent Tee Filter present? 0 Yes No If yes, was it cleaned? Yes E] No
5. Observed condition of component pumped:
9 0F 9A All of this estimated
information is non-bi.nd i,ng, va lid only.,at the time_ofpumpina. Not resp nsible be�y nd the date above.
............. ........ .......
6. System Pumped By:
Name Vehicle License Number
AS Development Corp. d/b/a Stewart I s, Septic
Service, 58 So. Kimball St., Bradford, MA 01835
7. Location where contents were disposed:
Ste wart's Receivin,gFacilit,y,,_...20Soo. Mall St., Bradford, MA 0183_5.� ...........
See above
........... ------ ....... ......................
Signature of Hauler data
..........
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc- 11/12 System Pumping Record#Page 1 of 1
own oT
Commonwealth of Massachusetts
APR 7 Z026
CTown of No. Andover
Sys tem Pumping Re cord
Health Department
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, 5
use only the tab -------- ............
key to move your Address
cursor-do not No. Andover MA 01845
use the return
key. City/Tow,n State Zip Code
W
2. System Owner-
Same 'N
- -----_---------
Name
Address(if different from location)
............... ------
City ../Town State Zip Code
---------------------
Telephone Number
B. Pumping Records
o7
1. Date of Pumping D-ate 2. Quantity Pumped. _Ga I-lions
3. Component- Cesspool(s) 0 Septic Tank El Tight Tank El Grease Trap
..... ......� _____.._ .�.�� 1 (A C
Other (describe):
4. Effluent Tee Filter present.? El Yes [K No If yes, was, it cleaned? Yes [:1 No
5. Observed condition of component pumped*
All of this estimated
information is non-biriding, valid only_at the time of pum n Not responsible beyand the date above.
6. System Pumped By:
/44
..........
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 Facilit , 20 So. Mill St., Bradford, MA 01835
y_ ......
6k&a els See above
.............-------- ------
Signature of Hauler to
Si_�. .......� . ... ..gnature of Receiving F acility(or attach facili ty receipt) Date
t5form4.doc,11/12 System Pumping Recor'd Page 1 of 1
V
Commonwealth of Massachusetts APR 7 2026
City/Town of No.Andover
Health Department
System Pumping Record
Form 4
DES has provided this for 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
cursor-do not
use the return ----------
key. City/Town State Zr Code
2. System Owner-
W
40
Nar ne
----------
Address(if different from location)
No.Andover MA
City/Town State Zip Code
....... Telephone Number,
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped.
Gallons
a
3. Component: Cesspool(s) Septic Tank Tight Tank Grease Trap
/*
_... ther(describe):
[ y
4. Effluent Tee Filter present? es [o.. If yes, was it cleaned? YesG....w... o
5. Observed con-fition of'component pumped�
1^
6. System Pumped By:
Name Vehicle License Number
Stewart's 58 So Kimball St. , Bradford,MA
Company
7. Location w here contents were disposed:
20 Sc. ill St.,Bradford,MA
CL
��64iure of Hauler Date
§6 n---afure of 6e_i V-in,,6, F_,,a-c_i lily(car'--a-tia 6"h, f---a-,c-,-iii-It—'re'",,66-ip'"-t),- -b-'a_te __`_,______
t5form4.doco 11/12 System Pumping Record-Page 1 of 1
Commonwealth of Massachusetts Town of North Andover
City/Town of No. And over
- 7 2026
APR
System Pumping Record
Form 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 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
Uh 2. System Owner*
Same
............ ..............
Name
.............. ------
Address(if different from location)
......................
City/Town State Zip Code
............ ............
Telephone Number
B. Pumping Record
;) �5
1. Date of Pumping ....... 2. Quantity Pumped:
Date Gallons
3. Componeft- Cess,pooll(s) [:1 Septic Tank El T'ight Tank 0 Grease Trap
"" ►z000* 'r I --
LIV (Z>L/� /A,-
Other(describe).:
4. Effluent Tee Filter present? E] Yes kIgo If yes, was it cleaned? El Yes
5. Observed co idition of component pumped-
All of this estimated
information is non-binding, valid only at the time of un Nn I`" apt repponsible beyend the date above.
6. System Pumpe
ot
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., 20 So. Mill St., Bradford, MA.-0,18,.,351
.�........___. _. ..... .. .�.......�_. ... .... ...�......._....w_____�........._...�...�� �........_.___..
c;2
See above
................ ............
Signature of Hauler Date
Signature of Receiving Facility(or attac h facility receipt) Date
t5form4.doc-&11/12 System Pumping Recordo Page 1 of 1