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Home My WebLink AboutBake and Joy Sludge Tank April 2026 - Septic Pumping Slip - 351 WILLOW STREET 4/3/2026 Commonwealth of Massachusetts.m _ . Town of Nofth Andover City/Town of No. An dover MAY - 6 2026 System Pumping Record Form 4 DEP has provided this for for use by local Boards of Health. Other f 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. Fac i lity I nformation Important:When filling out forms, 1. System Location: on the computer, use,only the tab U ........... key to move your Address cursor-do not No. Andover -- M 145 use the return --------- ke City/Town State Zip Code 2. System Owner- tab If'�? (AJ T" Same Name raw ---------------- Address(if different from location) ................. City/Town State Zip Code Telephone Number B,. Pumping Record I., Date of Pumping 2. Quantity Pumped. Date Gallons 3. Component- Cesspool(s) Septic Tank 0 Tight Tank El Grease Trap �9 Other(describe)- —----_ --l-,..,,.,..-,...--.--."-----.-,-.-S.,-.t,-.v-".- --.... g -.1- 4. Effluent Tee Filter present? 0 Yes [A No If yes, was it cleaned? [I Yes El No 5. Observed condition of component pumped: 300a, All of this estimated information is non-bi.nd.ipS yalid_on atthetimeof um.pin e be onda. the date above.Not res onsibi .............. 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 Receivin.gFacility,20 So. Mill St., Bradford, MA 01835 See above ....................... Signature of Hauler Date ............. Signature of Receiving Facility(or attach facility,receipt) to t5forrn4.doc*11/12 System Pumping Record Page 1 of I Town Of NOft,")Andover Commonwealth of Mass,achiusietts CA W City/Town, of No., Andover '6 2026 MAY - System Plumpling Recoirdi k� Form 41 Health 1 DEP has provided th�is form for use by local Boards of Health. Other forms may1q9R1a6tmQF# inform,at,i�oin must be substantially the,same as,that rovided here. Before using this form,I check with your local Board of Health to determine the form they use. The System Pumping Record must be subm,itted 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 foirms 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, C ity/Town State Zip,Code 2. System Owner: Same ................ ................. Name reun .............. ........................................................................... ......... Address if different from location) City/Town State Zip Code ......... .................... ............................................. Telephone Number B. Pumping Record, 1. Date of Pumping 2. Quantity Pumped: Date Gallons Component- Cesspool(s) Septic Tank Tight Tank El Grease Trap Other(describe): 4. Effluent Tee Filter resent? El Yes, No If yes, was it cleaned? El Yes El No 5. Observed condition, of component pumpled., C)6 All of this, estimated information is, non-,bindina, valid' oral t t h e time of_p umpina. Not resp nisible beyond the date above., 6. System Pumped By- Name Vehicle License Number ,J&S Development Corp. d/b/a Stewart's, Septic Bradford MA 0 1835 Service, Kimball St., ............... ....... 7. Location where contents were disposed: Stewart's Re�c,eivinn Facilit , 20 Sol., Mill St., Bradford,, MA 01835, See a bove ...... Signature of Hauler Date ............ ............ Signature of Re�ceiv,ing Facility(or attach facility receipt) Date t5form,4,.doice 11/12 System Pumping Record Page 1 of 1 4orth Andover TC, Commonwealth of Massachusetts MAY - 6 2026 City/Town of No., Andover 4j . -: 1- wa IQ System Pumping Record "a Djep: i ment Fo rm 4 DE,P 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 CIVIR 15-351. A. Facility Information Important:When filling out forms 1. System Location* on the computer, use only the tab ........... key to more your Address cursor-do not No. Andover MA 01845 use the return ...... ........... key. City/Town State Zip Code tab 0,W 2. System Owner- Same Name 7 Address if different from location) .............. City/Town State Zip Code Telephone Number B. Pumping Record )c 1. Date of Pumping Date 2. Quantity Pumped. Gallons 3. Component: Cesspool(s) Septic Tank El Tight Tank 0 Grease Trap [2/Other(describe)* ]0d 4. Effluent Tee Filter present? El Yes /N o If yes, was it cleaned? E] Yes No 5. Observed condition of component pumped- All of this esti mated mp(�_9.,. Not responsible be and the date above. valid o at the t information is non-bindirig., ime_of 6. System Pumped By: Name W. - Vehicle License Number J&S Development Corp. d/b/a Stewart Is 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 U of' a.tiler .......... ......... Signature of Receiving Facility(or attach facility,re cei . _.. .__.._ _..__._....... pt) Date t5form4.doc-11/12 System Pumping Record Page 1 of 1 Commonwealth of Massachusetts Town of' No�h Andover City/Town of No. Andover - 6 2026 MAY System Pumping Record Form 4 yy 6 n He a,,,y e.M1 v.a e 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 Impoftant:When filling out forms 1. System Location: on the computer, '35- M. 1 use only the tab .......... ------ key to move your Address cursor-do not No. Andover MA 01845 usethe return .......... ------ .................................. ........... .......... ............... key. City/Town State Zip Code tab 2. System Owner: Same ............ ............ --------------- ............... Name Address(i f different from location) City/Town State Zip Code Telephone Number B. Pu mping Reco rd C5 o 649 1 Date of Pumping Date 2. Quantity Pumped. G-a-11..on s 3. Component: Cesspool(s) Septic Tank Tight Tank El Grease Trap ....................... Other (describe): 4. Effluent Tee Filter present? 0 Yes Zk_No If yes, was it cleaned? E Yes El No 5. Observed edition of component pumped: "Aft 65-110re r All of this estimated - information is non-bindl..n,q,_,,,valid oni at the time of pumping. Not responsible be and the date above. ................... ------- ------- 6. System Pumped By. 405�v, (0 .......... ....... Name Vehicle License Number J&S Development Corp. d/b/a Stec art's Septic Service, 58 So. Kimball St., Bradford, MA 0 1835 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 IUM I V11 I'VVI U I rill 1UVVU1 Commonwealth of Massachusetts MAY -6 2026 City/Town of No. Andover System Pumping Record Health Depai�mpnt Form 4 DEP 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 ithin 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- Same ................ Name Address(if different from location) ............... City/Town State Zip Code Telephone Number B. Pumping Record dd 1. Date of Pumping 2. Quantity Pumped. Date Gallons 3. Component-, El Cesspool(s) El Septic Tank Tight Tank [I Grease Trap .2 ............Other(describe)�, 4. Effluent Tee Filter present? 0 Yes 20'00�No If yes, was it cleaned? Yes No 5. Observed ndition of component pumped, 101, -d= C7--o All of this estimated information is non-bindlin.g m s e be ond the date_above. ,_,,,,,,valid on_ly.at.the,time.of,__p,u ping. Not re p 6. System Pumped By: 49 n ge,5 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 e 4"A See above Signature of Hauler Date Signature of Receivin g Facility or attach facility receipt) Date t5form4.doco 11/12 System Pumping Record Page 1 of 1 TOWn Of North Andover Commonwealth of Massachusetts City/Town f No. Andover : _ MAY 2026 System Pumping R 4 t' Form � 3Hea fth e DEP has provided this form for use by local Boards of Health. OtherrrsLR&�,uq W t information rust be substantially the same as that provided here. Before using this fora, 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 data in accordance with 310 CIVIR 15.351. A. Facility Information Important:When filling out forms 1. System Location. ors the computer, _. use only the tab key to rove your Address cursor..do not o. Andover 1 45 usethe return pity/Torn . ___.____._.__. _...__._ _...__... a_..M....M......_._..._ .__.___.._m�_._._ .__. _. _fin .w__.....__w_...�.___ . �I d tate key. tab 2. SystemOwner: Same t1v __..w...._ _. .................. Name _.w Address If d fferent from location) City/Town....m..___...�..._W_.�.___.. ._�.�...__. _ State fate Zip Code . ._. ... Telephone Number B. Pumping Recor+ 1. Date of'P u m i n __________w _______ _..__.__.__..__ _._:_._._____. 2. u a n tity P u m ed: �._.__ 4 w_____w_..___.m_. .___-___. Date Gallons 3. Component: Cesspool(s)El) El Septic Tank El Tight"dank 0 Grease Trap )C9 Other(describe). _.__.....__._ __.........._._a._.. _.M.__a....__.._.... ._ 4. Effluent Tee Filter resent? El 'Yea o If yes, was it cleaned' 0 Yes F� No 5. Observed condition of component pumped: All of this estimated information is non bindin valid onl at the time of um an . Not responsible be and the date above. _.._.._._...._.__.....__.._......a...._ __._.....M_... m _.M.. ._. ._ _.. .,� l ........_ .�._w ..._...__.._.a.._..... _.M_. ... .......� __w.........._...._... . ..._.... w .__....__... .�� __.. ....._.....W. ... ..._..._ 6. System Pumped By: Name Vehicle License Dumber S Development Corp. d/b/a Stewart's Septic Service, 5 So. Kimball St., Bradford, M 01835 ....................... ............ 7.. Location where contents were disposed'. Ste rvart's Receavin .._Facil..it.�, 20 Se., Mill St., Bradford---------------------------, M C 1 35 Ile j0005;� See above ", Signature of hleule Date Signature of deceiving 1=acwlit... .-.....__. .._..w.._._.. y(or attach facility receipt) Date t5form4.doc-11/12 System Pumping l=eerd o Page 1 of Commonwealth of Massachusetts Town cl N_...__ _. o�h Andover City/Town of No.Andove:µ - . .. r - 6 2026 MAY 0 ............................... System Pumping Record 19 Form 4 Af 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 use the return key. City/Town State Zip Code V 2, System Owner- tab Q Name Address if different4rom location) No.Andover MA City/T wn State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date.................. 2. Quantity Pumped. Gallons 3. Component- Cesspool(s) Septic T ank Tight Tank Grease Trap lop [4ther(describe)- ................ ........... 4. Effluent Tee Filter present? Yes 0 If yes, was it cleaned? Yes No 5. Observed condition of component pumped- 6. System Pumped By- V Stewart's Se tic 58 So Kimball St. , Bradf and MA Company 7. Location where contents were disposed, 20 Se. ill St.„Bradford, 3" ler�a u)��i Date ------------ gna re of S`4n�fiur�---o' e",6-e,-,i'v'-i r"`gF,-aci I i t-y,-(o—ra t t-a-c-h"—f a-c...i-1i"i,y-,-r..e,6,--i"p_t)_ 'D,--a' t5form4.doc*11/12 System Pumping Recordo Page 1 of 1 Town of Nofth Andover Commonwealth of Massachusetts - 6 2026 City/Town of No.Andoverwm MAY Sys te u m 'li r Record Form 4 Hcalt'A Depaftment 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 11'rom the pumping date in accordance with 310 i"'.'.%1fIVlR 15.351. A. Facility Information Important:When filling out forms 1 System Location.- on the computer, use only the tab tv key to move your Address cursor-do not use the return key. City/Town State Zip Code 2. System Owner- tab Name Address(if different from location) ondover MA City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped- Date Gallons 3. Component: Cesspo�ol(s) Septic Tank Tight Tank Grease Trap Other(describe): U�13e 4. Effluent Tee Filter present? E Yes No If yes, was it cleaned? Yes No 5. Observed condition of component pumped- 6. System Pumped By- Vehicle License Number Ste art' Septic 58 So Kimball St. , Bradford,IVIA Company 7. Location where contents were disposed: 20 So.Mill St.,BradfordMA Signature of Hauler Date Signature of Receiving Facility or attach facility receipt) Date t5form4.doc-11/12 System Pumping Record-Page 1 of 1 Town Of North Ando Commonwealth. of Massachusetts _ mm_ . _ City/Town of No. Andover MAY aft' 62026 ........... System Pumping Record Form 4 De DEP has provided this form for use by local Boards of Health. Other forms may be used, nc 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 Pumpi,ng 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 A0 2. System Owner-, Same o Name Address if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2, Quantity Pumped. Date Gal ons, 3. Component- El Cesspool(s) El Septic Tank El Tight Tank 0 Grease Trap [0 Other(describe): Vj 4. Effluent Tee Filter present? Yes No If yes, was it cleaned? El Yes El No 5. Observed condition of component purnped* 2 o0j, All of this estimated information is non-bindip_gvalid only, at the time of u.uin g N.ot.'responsible be,�t nd the date above. m 6. System Pumped By: Name Vehicle License Number J&S Development Corp. d/b/a Ste wart'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 Noti AndOver MAY City/Town of No. Andover 2026 System Pumping Record Form 4 Heahh 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 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- 7 Same ............ Name ............ Address If different from location) .......... ...... City/Town State Zip Code ro Telephone Number B. Pumping Record t 1. Date of Pumping Date..._.._ 2. Quantity Pumped. 1-1 o ns S70 3. Component- Cesspool(s) Septic Tank [I Tight Tank F-1 Grease Trap S1[39 Other(describe)- V A ------ ......... 4. Effluent Tee Filter present? El Yes [g No If yes, was it cleaned? El Yes [I No 5. Observed condition of component pumped: All of this estimated Information-Ns non-bin ink,...valid on y the t time of pg Not res ponsible end the date above,, purn . 6. System Pumped By: Ck Ca-n .............. 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 Facilit , 20 So. Mill St., Bradford, MA 01835 4� See above Signature of Hauler Date .................... Signature of Receiving Facility or attach facility receipt) Date t5form4.doco 11/12 System Pumping Record Page 1 of 1 Commonwealth of Massachusetts lown of'Orth Andover 2026 City/Town of NoAndover System Pumpling, Record Form 4, rtMent D,EP, has provided this firs for use, by local Boards,of Health., Other forms may be used,, but the information miust be substantially they same as,that pirovidie�d here. B ire us,ing this forril check with your local Board of Health to determine the form they use., The System Pumping Record mulst ble submitted to the local Bolard of exult or other approving authority within 14, days,from the plumping date in accordance with 3,10 CMR 15.351. A. Facility Information Important:When filling out for 1 System Location: or on the computer, / use only the tab too) key to move your Address cursor-do not use,the return key. City/Town State Zip Code V 2. System Owner- "Ol Name Un Address if d1ifferent from location) N'o.Anidover MA City/Town State Z,ip Code Telephore Number B. Pumping Recoird 1. Date of Pumping b a't 2,. Quantity Purnped.. Galifons 3. Component- cesspool(s) Septic Tank Tight Tan�k Grease Trap Other(describe)" --------- s No 4. Effluent Tee Filter present?, Yes, No If yell, was it cleaned? Ye 5. Observed condition of compon rat uumped: 6. System Pumped Bly- so Name Vehicle License Number Sto.wart's Sep c '-8 So Kimball St�. Bradfoird,MA ny ---------- 7. Location where contents were dui posed.- 20, SoMlill St.,Bradford,MA ------------ signature f i:6,uler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc-11/12 System Pu ping Record P,ag!le 1 of 1 Commonwealth of Massachusetts, Of Not Andover MAY City/Town of No. Andover - 6 2026 Sys te m P u mping Re c o rd Form 4 C h Department Af 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 ng 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. ............... wood A. Facinty, Information Important:When filling out forms 1 a System Location.- on the cornputer, useony the tab 3V key to move your Address cursor-do not No. Andover MA 01845 use the return ......... ......................... key. City/Town State Zip Code 18b 2. System Owner- Same Name 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) Septic Tank Tight Tank Grease Trap ZOO�Other(describe): ........ 4. Effluent Tee Filter present? El Yes a No If yes, was it cleaned? Yes [:1 No 5. Observed condition of component pumped: r-01-006 All of this estimated information is non-bindle only,at the time of be Not responsible and the date above. 6. System Pumped B Name Vehicle License Nu�mber 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 Facilit , 20 So. Mill St., Bradford, MA 01835 � ..._ b � _.__._..__........m_0�e ------ Signature of Hauler Date ........... ............................. --------------- Signature of Receiving Facility(or attach facility receipt) Date t5form4,doco 11/12 System Pumping Record#Page 1 of 1 Pit luover Commonwealth f Massachusetts MAY 6 2026 z City/Town of No. Andover F System Pumplang Record 1 1, D e. Form 4 3rtMent DEP 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 0 11 key to move your Address cursor-do not keey. Noy./Andover ... A - 18�45 re .... .... ---------- us the CitTown State Zip Code W 2. System Owner: Same Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1711& i ----y.................... .............. ........... 2. Quantity Pumped*1. Date of Pumping Date G'allons 3. Component- El Cesspool(s) Ej Septic Tank 0 Tight Tank E] Grease Trap S� Ug EROther(d escribe): ......................................... C,._11-1-_________1-1-_11-1---1_------------- ---------- 4. Effluent Tee Filter present? Yes No If yes, was it cleaned? [I Yes El No 5. Observed condition of component pumped: All of this estimated information is non-bindip_q_...valid on_l,y_,_at,,,t,h.e time of pum,pjn g. Not responsible,,,beyqnd the date above. ............ 6. System Pumped By: llj�.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 Receiving,Face lit 20 So. Mill St., Bradford, MA 0 1835 . ... W.... .._._�_ .......... ......... ------- See a .... bove....... Signature of Hauler Date ............ Signature of Receiving Facility(or attach facility receipt) Date t5form4.doco 11/12 System Pumping Record*Page 1 of 1 Commonwealth of Massachusetts To" Of N011 AndWer --- Cif To n of No. Andover :. MAY - 6 2026 System Pumpin ecor d Form 4 Af Hoalth Depa DEP has provided this for for use by local Boards of Health., Other forms may be usen, T90t 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 frolm 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-, Same --------------- Name ratio ......................... . .................... ----------- Address if different from location) City/Town State Zip Code Telephone Number B. Pumping Record ).POO I Date of Pumping Da.te 2. Quantity Pumped. Ga.llon.s 3. Component: Cesspool(s) 0 Septic Tank El Tight Tank El Grease Trap 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-bindina. valid only at the time___qf_p .,.,,Not res onsible beyq�d the date above. y p,n 6. System Pumped By: Name Vehicle License Number J&S Development Corp. d/b/a Stewart Is Septic Service, 58 So. Kimball St., Bradford, MA 01835 7. Location where contents were disposed: Ste wart's Receivi.99 Facilit , 2,0 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 Recordo Page 1 of 1 �11111 Commonwealth of Massachusetts TOwn Of NOt Andover City/Town of No. Andover :. MAY 2026 System P m p Record Form 4 Health Depaq DEP has provided this form for use by local Boards of Health. Other forms may be used, bUL Tte nt information must be substantially the same as that provided here. Before using this,form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important-When filling out forms 1. System Location- on the computer', 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: tab Same Name MW j;W Address(if different from location) _____.............. .......... ........... City/Town State Zip Code Telephone Number .......... B. Pumping Record 0" 1. Date of Pumping 2. Quantity Pumped. Gallon e 3. Component. El Cesspool(s) El Septic Tank E] Tight Tan rease Trap Other(describe): ------ 4. Effluent Tee Filter present? [:1 Yes No If yes, was it cleaned? Yes [:1 No 5. Observe-1 condition of component pumped: aQ N All of this estimated information is nolUhnding.,valid oral at the time of.,p_y,Mjpipq.,flat responsible beyond the data above. .......... 6. Syste rued rr ........... ..................................... ............................................................................. ....... Name Vehicle License Number J&S Development Corp. d/b/a Ste art's Septic Service, 58 So. Kimball St., Bradford, MA 01835 ............. 7. Location where contents were disposed: Sty wart's 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- 11/12 System Pumping Recordo Page 1 of 1 Commonwealth of Massachusetts Town of Nod Andover, City/'Town of NoAndover MAY 2026 System Pumpling Reicord --------- tA% Foirm ilt DepnrtMent D,EP has provided thilis,form:foir use by local Boards ofHealth, Other forms, may be us,edl, but,the information must be substantially the, same as that provided here. Before using this form, check with your local Board of Health to deitermin!e the form they use, The System Pumping Record must be subirnitted to the local! Board of Health or other ap roving!, authority with!in 114 days from the purnping date in accor'danice with 31O CMR 15.3511., A. Facility Information Important: per filling out forms 1. System Locatiioin'. on the computer, use only the tab key to move your cursor-do not use the return -------------- ........ keiy. City/Town State Zip Code 2, System Owine�r: Aj team Add�resis(if d,ifferent from location) Noi,.Andover MA City/Town State Zip Code Telephone Number B, Plumping Reicord Gallons 1 Date of Pumping ........................... 2. Quantity Pumped ----k Dial, Grease Trap Tight Tank 3. Component- Cesspool(s) Septic Tank 1101 4 ---------- "her(describe). ....................... 4. Effluent Tee Filter present? Y e,s, �,��1 N o, If yes, was it cleaned? Yes No 5. Observed ondition of component plumip:edi- ............ 6. System Pum ped By: .................. Name V'ehic,le License Number Stewart�'s Septic 58 S Kimball St. Bradford,MA Company 7. Location whiere contents were dilsposedl- i 20 SoMill St.,113radford,MA 00e „,�/ a Signature of Hauler Date C-ig--na-t-u-r e-,of R e-c--e i-v--i n'g- F—a c-i I i&y,-,("-o-r-ai--t a-c-h--f-a'-c"i-1�'t"...y--r-ie-c-e"i-p-t)-1, ....... t5form4-doc* 11/12 System Pumping Record Page 1 of 1 Town of Nottl I Andwer C of Massachu sets . . _ _nnf No. Andover MA Y 6 2026 System Pu g Record mpin 0 Form 4 Health Del, DEP has provided this form for use by local Boards of Health. Other forms may be useb bill�� 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 Informati I on Important-When filling out forms I System Lo cation- (NI 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, a Name repo ................ --------- Address(if different from location) City/Town State Zip Code Telephone Number Pumping Record 1. Date of Pumping 2. Quantity Pumped. Date Gallons 3. Component, Less l(s) [I Septic Tank E:1 Tight Tank El Grease Trap ther(describe). 4. Effluent Tee Filter present? Yes If yes, was it cleaned? E] Yes E] N o 5. Observed condition of component pumped* All of this estimated information is non-bi ndi!jg,,,,.va lid only at the time,of um In Not resp sible bey9nd the date above. 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 dispo saki: Ste wart's Receiving Facilit 20 So. Mill St., Bradford, MA 01835 000, 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