HomeMy WebLinkAboutMay 2026 Bake N Joy - Septic Pumping Slip - 351 WILLOW STREET 5/31/2026 Town of No�f`i Andover
:�L\ Commonwealth of Massachusetts
2026
61 City/Town of No. Andover JUN 1;
Z
System Pumping Record
Form 4 Health Departm(,,int
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before us,ing, this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31 MR 15.351.
A. Faci l ity 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 -0 18,4 5
use the return key. City/Town State Zip Code
db tG1 2. System Owner:
tab
Same
Name
Address(if different from location)
..........
.__-_.. ._ _.._._...... .
City/Town State Zip Code
.............__._.._.__.............
Telephone Number
B. Pumping Record
I S 0 6
1. Date of Pumping ........ .......... 2. Quantity Pumped:
Date G, Ions
3. Component: Cess,pool(s) F1 Septic Tank El Tight Tank '[1 Grease Trap
[�4 Other(describe):
4. Effluent Tee Filter present? E:1 Yes No If yes, was it cleaned? n Yes R No
5. Observed condition of component pumped:
2004 All of this estimated
information is non-binding, vapid only at the time of._p responsibile be and the date above.
6. System Pumped By:
/111 qIS avrN ............ ...........
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 Rec�� Facilit .., 20 So. Mill St., Bradford, MA 01835
......................... ......
's See above
Signature of Hauler Date
Signature of Receiving Facility, or attach facility receipt) Date
t5form4.docq, 11/12 System Pumping Recordo Page,1 of 1
Commonwealth of Massachusetts T30Wil of NOrth Andover
z 11 IT City/Town of No. Andover
2, 26
T JUN 1"'
>
System Pumping Record
Mr Form 4 Ilea 1."h Depaftme,nt
#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 31'�O 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
tab 2. System Owner:
Same
Name
few
Address(if different from location)
Cityffown State Zip Code
Telephone Number
B. Pumping Record
15 suo
1. Date of Pumping Date J, 2,., Quantity Pumped: Gallo
3. Component: El Cesspool(s) Septic Tank [:] Tight Tank F] Grease Trap
Z1 Other(describe _.._.. 0.................. ......... -......
4. Effluent Tee Filter present? 0 Yes No If yes, was it cleaned? Ej Yes F1 No
5. Observed condition of component pumped:
]00 All of this estimated
information is non-binding, valid only at the time of pumping. p Not reonsible beyond, the data above.
6. System Pumped By:
Orr,
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 di'sposed:
Stewart's Receiving Faqility,..20 So. Mill St., Bradford, MA 01835--...
-To Y,-e S See above
Signature of Hauler Date
Signature of Re eiving Facility or attach facility receipt) Date
t5form,4.doco, 11/12 System Pumping Record Page 1 of'l
� Commonwealth of MassachusettsTown Of NOM
.................. Andover
M City/Town of No.Andover
JUN 11.
2026
W System Pumping Record
`4 Form 4 CC
�..
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
use the return CitylTown State Zip Code
key.
tab 2. System Owner:
t
t�r
Name
reran
Address of different from location)
No-Andover MA
City/Town State Zip code
Telephone Number
Br Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date GalIbns
3. Component: [❑ Cesspool(s) L Septic Tank Tight Tank Crease Trap
❑ other(describe):
4. Effluent Tee Filter present? E Yes No if yes, was it cleaned? El Yes F-1 No
5. Observed condition of component pumped:
6. System mped' y-
Nam6 ij Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So t. Wadfor A
...........
Signature of Hauler...... ......... -:� Date
Signature of Receiving Facility for attach facility receipt) Date
t5form4.doc•1111 Z System Pumping Record•Page 1 of 1
Ttbv�qj '1VO4h Andove
Cornmonwtealth of Massachusetts
City/Town, of No. Andover
JUN 1 .- 2026
>
System Pumping Record
Form 4
[�o "�"�
Det) rtment
DEP has provided this form for use by local Boards of Health. Other forms may be used, but M
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, VW
use only the tab
key,to move your Address
cursor-do not -No. Andover MA 01845
use the return,
key. City/Tolwn State Zip Code
2. System ner:
tab Ow .0<
Same /zlv
Name
oun X
Address,(if different from location)
City/Town State Zip Code
Telephone Number
B. Pump"I ng Record
1. Date of Pumping Date 2. Quantity Pumped: G lens.._. .
3. Component: Cesspool(s) E:1 Septic Tank Tight Tank E Grease Trap
El Other(describe): ..........
4. Effluent Tee Filter present? El Yes 0 No If yes, was it cleaned? Yes No
5. Observed condition of component pum '.0 d
All of this estimated
information is non-bindling, valid only at the time of pyMp,iq_g. Nqf. q the date above.,
6. Syst m Pur,1, ed B
Fu Iz!
Na(ne 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 we,rerd': o,,S,
s r
Stewcll r,t,'!5r'�e �i,vinKFaciJ 0. Mj"Ro$<., BSa4f6W, MA 01835
See above
Signature 6f"Rauler Date
Signature of Receiving Facility(o�r attach facility receipt) Date
t5form4.doce 11/12 System Pumping:record Page 1 of 1
Commonwealth of Massachusetts OfNkortih Andover
City/Towrl of No. Andover
- 226
J UN
..........
System Pump"Ing Record
Form 4
DepatIment
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, data in
accordance with 310 CIVIR 15.351.
A. Facil ity I nformation
Important,:,When
filling out forms, I 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
tdb
2. System Owner:
"_ wl o e )
Same
Name
Address(if different from location)
City/Town State Zip Code
.............
Telephone Number
B. Pumping, Record
1. Date of Pumping Date 2. Quantity Purnped: Gallons .......
3. Component: D Cesspool'(s) El Septic Tank Tight Tank E] Grease Trap
..........
01-110Other(describe):
..
................. .
4. Effluent Tee Filter present? ® Yes a 14o If yes, was it cleaned? E] Yes No
5. Observed condition of component pumped:
Al'l of this estimated
-information is non-binding, valid op�y at the time p e data above.
6. System Pumped By:
O�
........
Name Vehicle License Number
AS Developmient Corp. d/b/a Stewart's Septic
-Service, 58 Sc. Kimball St., Bradford', MA 01835
7. Location where contents were,disposed:
-Stewart's Receiving F�,20 So. Mill St., Bradford, MA 01835
00
See above
..........
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t form4.doco 11112 System:Pumping Record Page 1 of 1,
f k
Commonwealth of Massachusetts 04 Andover
"*tyare Town of No. And
i over
lox, U1
2026
J[J N I
System Pumpng Record
Form 4
At
Department
DIE,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 for,m�, 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 plumping date in
accordance with 31 MR 15.351.
A. Facility Information
Important:When
filling out forms 1 System Location:
on the,comiputer,
use only the tab .......
key to move your Address
cursor_do not -Nol. Andover MA 01845
use the return key. City/Town State Zip Code
2,. System Owner: 101%
/11
Same
Name
Address If different from location)
CityfTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallio ns
3,. Component: E:1 Cesspool(s) E:1 Septic Tank 0 Tight Tank El G,rease Trap
..........
00
DI Other(describe):
4. Effluent Tee Filter present? F I Yes E] 0' If yes, was it cleaned? M Yes El No
5. Observed cqqdition of component pumped:
.... ..........
All of this estimated
information is non-bindingvalid o.nl at the time of ing. Not responsible beyond the data above.
ey_
6. System Pumped By:
r
Name Vehicle License Number
J�&S Development Corp. d/b/a Stewart's Septic
Service, 58 So, Kimball St., Bradford,) MAC 1 35
7. Location where contents were disposed:
Stewart's Receiving-Facility, 20 Sol. Mill St., Bradford, MA 01835
000
See above
.......... ..........
Signature of Hauler Date
Signature of Receiving Facillity(or attach facility receipt) Date
t5form4.doc*111/12 System Pumping Record Page 1 of 1
9 1 1 bwfl f North Andover
Commonwealth of Massachusetts
City/Town of No. Andover JUN 1,-- 2026
System Pumping Record
4r
Form 4 � �
Pat tment
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 018451
use the return City/Town State Zip Code
key.
2. System Owner:
110 tab
e.
Same
Name
Address(if different from location)
.........................
City/Town State Zip Code
Telephone Number
B. Pumping, Record
ir,
1. Date of Pumping Date 2. Quantity Pumped: Gallons ..........
3. Component: El Cesspqol(s) E Septic Tank E:1 Tight Tank E] Grease Trap
.............
O
e-10
1
ther(describe):
4. Effluent Tee Filter present? Yes [11� o If yes, was it cleaned? 0 Yes d N1 0
5. Observed C edition of component pumped:
,Ile............. Or
All of this estimated
9
7-
information is non-binding, valid' only at the time of py.MpTg. Not responsible be nd the date above.
6. System Pumped By:
00
1011101 ...........
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 Rec e iving Facil ityZP_So. Mill St., Bradford, MA 01835
%C2
sa
See above ol, 014- MLo"O
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doco 11/12 System Dumping Recordo Page 1 of 1
Commonwealth of Massachusetts V" Of Nofth Andover
&A City/Town o o. + ov
er JUN 1- 2,026
>
System Pumpi`ng Kecord
Form 4 'l Department
DPP 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 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
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code
2. System Owner:
............
[eon
Address(if different from location)
No.Andover------. MA
City/Town State Zip Code
Telephone Number
B. Pumping Record 47
to
U
1'. Date of Pumping 2. Quantity Pumped; Gallons
3. Component: L] Cesspool(s) E] Septic Tank Tight Tank Grease Trap
I(."" , l .........
.........
C/
2;111�0006ther(describe):
4. Effluent Tee Filter present? Yes No If yes, was it,cleaned? Yes No
5. Observed condition of component pumped:
6. System Pumped' By-
000
Name Vehicle License,Number
Stewart�§� tie �o l irmhall fit. ,.__Pradford,MA
Company
7. Location where contents were disposed:
20 Sol. ill St.,BradfordMA
...........
IP
gum
Signature of Hauler Date
Signature,of Receiving Facility(or attach facility receipt) Date
t5form4.doc*11/12 System Pumping Recordo Page I of 1
Lvvrii
��aa Nofth Andover
Commonweafth of Massachusetts
w u City/Town ofNo.AndoverJUN202fi
S stern PumpingRecord
y
Form 4
P
r,h D'4! a ftm e n
DEP has provided this, form for use by local Boar ds of Health. Other terms 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. -rhe System Pu►iiping 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 CUR 15.351.
A. Facility lnfo�%mation
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 City/Town ...............
key. State - _ Zip Code
r� 2. System owner:
. .� 710/t
Name
re�srr
Address(if different from location) �
No.Andover MA
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 [.❑ Night Tank Grease Trap
[❑❑ Other(describe):
4. Effluent Tee Filter present? D Yes [ µI No If yes, was it cleaned? ❑ Yes ❑❑ No
5. Observed condition of corn onent pumped:
5. System Pumpe y:
Name Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So.W t.,Br d or A
nature of H uler� � � _....._..._ Date -�
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•1 1/12 System Pumping Record•Page 1 of I
N'r i Andover
Commonwealth of Massachusetts
City/Town of No. Andover
__
2026
System Pumping Record J'U N 1,
Form 4
A I 5,j
il 71 ,ont
DEP has provided this form for use by local Boards of Health. Other forms may e Gsep,. ut Fh
' 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 oir other approving authority within 14 days from the pumping data in
accordance with 310 CMR 151.351.
A. Facility Information
Important:When
filling out forms 1 System Location: S�L
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 6(7.
Name
taun
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,
Other(describe).- �61 lu
4. Effluent Tee Filter present? 0 Yes E No If yes, was it cleaned? 0 Yes El No
5. Observed condition of component pumped;:
All of this estimated'
information is non-bin.ding, va rid only6ft the time of purin g. Nqt_� ble date above.
6. System Pura ed By:
Name Vehicle License Number
J&S Development Corp., d/b/a Stewart's Septic
Service, 58 So. Kimball St., Bradford', MA 011835
7. Location where contents were disposed:
Stewart's Receiv,i Facilit 0 So. Mill St., Bradford,
MA 011 35
See above
at r auler Date
...........
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.docle 11/12 System Pumping Record•Page 1 of I
vor
Commonwealth of Massachusetts A
low*&
Uity/Town of' No. Andover
'
System Pumping Record JUN I, 2d"26
Fo'rm 4
lb
Uient
DEP has provided this form for use by local Boards of Health. Other forms rn��v dtapab 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 CIVIR 15.351.
A. Facility Information
Important-When
filling out forms 1. System Location:
on the computer,
use only the tab LL) fV V0
key to move your Address
cursor-do not -No. Andover MA 01845
use the rotaey. City/Town; State Zip Code
k
NO 18b 2. System Owner:
Same
jj .................. ....... .....................
Name
Address if different from location)
Cityff own State Zip Code
............
Telephone Number
B. Pumping Record
1. Date of Pumpling 2. Quantity Pumped:
Date GalWs
3,. Component: Cesspolol(s) E:1 Septic Tank E] Ti'ght'Tank Ll Grease Trap
...... ........... ....
El Other(describe): . ..
4. Effluent,Tee Filter present? 0 Yes No If yes,, was it cleaned? Yes No
5. Observed'' condition of component pumped:
All of this estimated
information is non-binding valid only at the time o f pumipinq. Noll responsible beyond 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 01'835
7. Location where contents were disposed:
Stewart s Rep pi F 20 So. Mill St., Bradford,, MA 01835
__ying. ........ ......"we
See above
A
&
urfHda er Date
..........
of Receiving Facility(or attach facility rece,ipt) date
ate
11/12 System Pumping Record Page 1 of 1
'Oro 0 No�`,i Andover
Commonwealth of Massachusetts vin of
City/Town of No�. Andover
System Pumping Record JUN 1.- 2026
Form 4
At 14
DEP has provided this form for use by local Board's of Health. Other form
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. A_�. ndover MA 01845
use the return key. City/Town State Zip Code
2. System Owner:
V
tab Q ZZ
Same
Name
..... ..............
Address if different from location)
City/Town State Zip Code
Telephone Number
B. ing Record
7
1. Date of Pumping 2. Quantity Pumped: rJon
Date G�511 4 n,s
3. Component: E Cesspool(s) El Septic Tank El Tight Tank Ej Grease Trap
[� Other(describe): S ( U� 9- .................
4. Effluent Tee Filter present? D Yes No If yes, was it cleaned? Yes 0 No
5. Observed condition of component pumped:
All of this, estimated
information is non-binoigg,.valid only at the time of pyTping. Not responsible beyq�d the date above.
6. System Pumped By:
,14�fl 01 S ........... .............
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service, 58 So. Kimball St., Bradford, MA O1'835
7. Location where contents were disposed:
Stewart's, Receiving F acilit ITy, 20 So. Mill St., Bradford, MA 01835
S og See above
.signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc,, 11112 System Pumping Record Page 1 of 1
Town of Notri Andover
. CommonwealthMassachusettsof
w - w City/Town of No.Andover
JUN 1- 2026
a
w
System Pumping Record
ePartForm 4Health ���t
-r f 14.E
U
DEP has provided this form for use by local Boards of Health. Other farms 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
use the return City/Town State Zip Code
key.
2. System Owner:
Name
retr�r
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record --_
4
1. Date of Pumping oat �. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe): L)� ge,
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? Fj Yes F No
5. Observed condition of component pumped:
00 a
5. System Pumped By:
IA4 Q
Name Vehicle License Number
Stewart's Se tic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
Toy,-ec - -1�/I q/0-v
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doce 9`/12 System Pumping Record o Page I of 1
Town I
�L\ Commonwealth of Massach usetts ()f NOW)Andover
z
City/Town of No. Andover
2026
> UN I
System Pumping Record
Form 4
IT .
At g'4$
Healtil
(taont
S`u
DEP has provided this form for use by local Boards of Health. Other forms may be useb-,
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 CAM R 15.3511.
A. ifi 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
CJ-11
Name
Run
Address if different from location)
city Town State Zip Code
Telephone Number
Pu,mpoing Record
1. Date of Pumpingi Date 2. Quantity Pumped: Gallons
3. Com�pogent: El Cesspool(s) El Septic Tank El Tight Tank Grease Trap
[1 01 ell "'71
10�
Other describe):
r"J
oolo'01111101 1, / 0, , 11'""I "'o/ e;
Lz' ��("(",'� jo�"
(
4. Effluent Tee Filter present? El Yes E:1 No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
All of this estimated
information is, non-bindin ,ITIT valid only at the time of puMpTg. Not res onsible beyond the date above.
9
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:
ate
war°s Receiving Facility, 20 So. Mi ll St., Bradford, MA 01835
...........
1101L . ............
�� See above,(,,,,,
`Sid�ature of Hau'ler Date
Signature of Receiving Facility(or attach facility receipt), Date
t5form4.doce 11112 System Pumpilng Record•Page 1 of 1
I Commonwealth of Massachusetts, Town of North A ndover
City/Town of No. l ver
System Pumping Record 2026
JUN 1,
Form 4
At
CEP has provided this form for use by local Boards, of Health. Other
n.,
information must be substantially the same as that provided here., Before using this am, check wit 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 to ....
key to move your Address
cursor-do not -No. Andover MA 01845
use the return
key. City/T'own State Zip Code
2. System Owner:
Irdb
Same te A/
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
77'z
....
1. Date of Pumping ......Date 2. Quantity Pumped: Gallons
3., Component: Cesspool(s) El Septic Tank 0 Tight Tank El Grease Trap
'7
LIZ 0�1
...........
Other(describe): .......
If I ell
.............
4. Effluent Tee Filter present? Ye s If you, was, it cleaned? Yes No
5. Observed c,,pndition of'col ponent pumped:
All of this estimated
information is non-binqip_g, valid only at the time of pumping. Not responsible beyond the:date above.-
6. System Pumped !ww
ec, S`
41 610
6
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 Receiyi�F ill St., Bradford, MA 0 1835
oll
VIN ........LV�—(-_-,," See above_.-—
Signature of Hauler Date
Signature of Receiving Facility or attach facility receipt) Date
t5form4.doce 11/12 System Pumping Record Page 1 of 1
Commonwealth of Massachusetts t�!ONI Ando
City/Town of No.Andover
System Pumpl"ng Record JUN 1, 2026
Form 4
DEP has provided this form for use by local Boards of Health. Other forms r r U rupa,14M
information must be substantially the same as that provided here. Before using this form, che,TZ� Vith 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 CIF 15.351,
A.1 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 Zip Code
W 2. System Owner.-
Name
Address(if different from location)
No.Andover—, MA
City/Town State Zip Code
Telephone N6-,,—qbp,r
B. Pumping Record
1. Date of Pumping Da t6 2. Quantity Pumped: Gallons
3. Component: Cesspo�ol(s) Septic Tank Tig!ht Tank se Trap
Girea
4,0
10"' u�'°" oin imwiowuw I � V � s' vat
Other(describe):
4. Effluent Tee Filter present? Yes j e1"No If yes, was it cleaned? El "es No
5. Observed conidition, of component pumped-
0",111101110
6. System Pumped By:
Name Vehicle License Number
Stewart's
Company
7. Location where contents were disposed:
20 SoMill St.,Bradfoirdi IMA
pA
Signature of Hauler Date
Signature of Receiving Facility(or attach facility •receipt) Date
t5form4,doc*11/12 System Pumping Record-Page 1 of I
0 V14V)
Commonwealth of Massachusetts
Ando
. ............ Ve
City/Town of No. Andover
V
A
System Pump"Ing Record JUN I':
2026
- . Form 4
f SIN lb
j
DEP has provided this form for use by local Boards of Health. Other forms may, 6�Wsftc
i'nformatioln must be substantially the same as that provided here. Before using this form, checr\ 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, 6-1,
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 A/
Name
Run
Address if different from location)
........
City '"own State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Compo ant: ] Cesspoo,l(s) Septic'Tank Tight Tank E:1 Grease Trap
01
ex
("'J
Other (describe): tl'
4. Effluent Tee Filter present? 0 Yes-D,7No If yes, was it cleaned? Yes 0 No
5. Observed pondition of component pumped:
All of this estimated
information is non-bi ndiM,valid only at the time of-pumping. Not_Tspqnsible b�yqno..the date above.
6. System Pumped By:
Or
Name Vehicle License Number
J&S Development Corp. d/b/a. Stewart's Septic
Service, 5 So. Kimball St., Bradford, MA 0183,5
7. Location where contents were disposed:
Stewart s Recqly*N Facility, So. lllll St.,, Bradford, MA 018,35
See above
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doca 11/12 System Pumping Record Page 1 of 1
Commonwealth of Massachusetts Town OTNOrth Andover
Cat owl of No. Andover
Oki System Pumping Record JUN 1,- 2026
Form 4
A f 5,4 4
DEP has provided this form fore use by local Boards,of Health. Other fo494 _bDii4a" bUTPren(
information must be substantially the same as that prov'ided here. Before using this form, check wit,, your
locale 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 City/Town State Zip Code
key.
tab 2. System Owner:
Same
Name
[eon
Address if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping D Gal on 2. Quantity Pumped: ........
pc�
ate s
3. Component: F] Cesspool(s) El Septic Tank 0 Tight Tank 0 Grease Trap
Other(describe):
4. Effluent Tee Filter present? [:] Yes No, If yes, was it cleaned? Yes 0 No
5. Observed condition of component pumped:
� 0(j A All of this estimated
information is non-binding, valid on!ly_at the time of pumping. Not responsible beyond the date above.
6. System Pumped By:
1114 cl_�:aA.
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 0!1835
o See above
Signatureof Hauler Date
Signature of Receiving,Facility(or attach facility receipt) Date
t5form4.doce 11/12 System Pumping Record o Page 1 of 1
Commonwea lth of Massachusetts
. ........." I VV
i ," W dover
System Pumpi,ng Record JUN 1 2026
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may e us&Nuf MM e t
information must be substantially the same as that provided here. Before using this form, check wit your
local Board of Health to determine the form they use. The System Pumping Record rnus,t 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 I. System Location.:
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return No. Andover- MA
key. City/Town State Zip Code2. System Owner.
rib
Same
Name
few
Address(if different from location,)
City/Town, State Zip Code
Telephone Number
B. Pumping Reco,rd
S-0,0
1. Date of Pumping 2. Quantity Pumped: I
Date Gallons
3. Component: Ej Cesspool(s) El Septic Tank 0 Tight Tank E Grease Trap
[Z Other(describe): 9 C,
4. Effluent Tee Filter present? E:1 Yes R No If yes, was it cleaned? E:1 Yes E] No
51. Observed condition of component pumped:
2 0 6 All of this estimated
information is non-binding, valid on"tffie t!M u Not re onsiblab he data above.
6. System Pumped By:
,M a.,
Name Vehicle License Number
J&S Development Corp. d/bi/a Stewart's Septic
Service, 58 So. Kimball St., Bradford, MA 01835
7. Location where contents,were disposed:
Stew Receivi.R"Fcility, Mill eta Bradford MA 01835
4L 9 a A#v See above
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doce 11/12 System Pumping Record Page 1 of 1