HomeMy WebLinkAboutJune 2026 Bake N Joy - Septic Pumping Slip - 351 WILLOW STREET 6/2/2026 uwn of
IVOrth 4ndover
��Q- Commonwealth of Massachusetts JUL
City/Town of No.Andover...........
7' 2026
._ System PuRecord Health Depat,
Form 4 + �
raAl
SvB
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, -Ile ZI/ (s-:4
use only the t a b
key to move your Address
cursor-do not
use the return City/Town __ State Zip Code
key.
2. System owner:
rah `
Name
Address(if different from location)
No.Andover MA _
City/Town State Zip Code
Telephone Nun nber
B. Pumping Record
o
1. Date of Pumping Date Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank [❑ Tight Tank _ Grease Trap
St VA
[y Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. observed condition of component:pumped:
5. System Pumped By:
a- Qrl _
Name _ Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
1114 1;1-4�011 J70CAI
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•1111 2 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts Town of Nofth Andover
City/Town of No. An d over
Syste�m Pumping Record JUL
-'l 22 '
Form 4
DEP has provided this form for use by local Boards of Health. Other foki"Jheo"PVet kWi your
I' must be substanitially the same as that provided here., Before using this for
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 31.0 CI R 15.351.
A. Faci l ity I nformation
Important:When
filling out forms 1 System Location:
on the computer, (6
use only the tab
key to move your Address
cursor-do not -No. Andover MA 01845
use the return key. City/Town State Zip Code
2. System Owner:
Same
Name
Address(if different from location)
........................
City/Town State Zip Code
................ .......
Telephone Number
B. Pum!ping Record
5 0
1. Date of Pumping Date 2., Quantity Pumped: Gallons
3. Component: F-1 Cesspools e!ptic Tank Tight Tank Grease Trap
Other(describe): At_
4. Effluent Tee Filter present? 0 Yes No If yes, was it cleaned? F1 Yes E] No
5. Observed condition of component pumped:
10(j A All of this estimated
inform at�ion is non-�bindinig, valid only a�the time,of pumping. Not responsible be ie date above.
th
6. System Pumped By:
,M�s 01ri ____ - -
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 Deceiving Facility, 20 So. Mill St., Bradford, MA 01835
See above
Signature of Hauler Date
.Signature...........
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc*11/12
System Pumping Record Page 1 of 1
Town of N'oft,�Andover
Commonwealth of Massachusetts
JUL 2026
zw of No. Andover
mm
10 System, Pumping Record
Hoah'11 Desfta::: mp-n
Form 4 rfi.q Wo I
t
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
informati'on 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 ClVIR 15.351.
A. Facility Information
Important:When
filling out forms 1 System Location:
on the computer,
use only the tab .............. flotv P—
ley to move your Address
cursor-do not No. Andover MA 01845
use the return . ......
key. City/Town State Zip Code
tdb
2. System Owner: 4C
Same
Name
few
Address(if different from location)
..............
City/Town State Zip Code
...........
Telephone Number
B. Pumping Record
511,-, 11z C
1. Date of Pumping Date 2. Quantity Pumped: Gallons,
3. Component: El Cesspool ) El Septic Tank El 'Tight Tank El Grease Trap
5 1 vjp-1 A 0,
Other(describe):
4. Effluent Tee Filter present? El Yes No If yes, was it cleaned? 0 Yes Ej No
5. Observed endiitien of component pumped:
I ) All of this estimated
information is non-blin valid oV at the time of n ble beyqpq.,..
ding, _pympi-......-g_,Not.j��on§j. beyond the date above.
6. Systel—I Pumped By:
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service, 58 So. Kimball St.,, Bradford, MA 0,1835
7. Location where contents were disposed:
Stewart's Receivga 35F , , A
See above
n f Hauler Date
Signature of Receiving Facility for attach facility receipt) ...........Date
t5form4.docs 11/12 System Pumping record e Page 1 of 1
1()Wfl U1 II i r%i tvv v vs
Commonwealth of Massachusetts JUL 00417 2026
City/Town of No. Andover
System Pumping Record Ith Department
H e
wqr
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 data in
accordance with! 310 CMR 15.351,
A. Facility Information
Important:When
filling,out forms 1 System Location:
on the computer, S
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
tee
Address(if different from location)
City/Town State Zip Code
Telephone Number
13, Pu�mpling Rec,olrd
1. Data of Pumping Date 2. Quantity Pumped: Gailons
3. Component: Cesspool(s) 0 Septic Tank M Tight Tank E] Grease Trap
12/Other(describe):
4. Effluent Tee Filter present? Ell Yes No If yes, was it cleaned? E:1 Yes Ej No
5. Observed condition of component pumped:
All of this estimated
informations non-lbind'in I valid onl inae ti fum n s i b I ond the data above.
e
6. System- Pumped y:
Name Vehicle License Number
J&S Development Corp,. d/b/a Stewart's, Septic
I
service, 5l8 So. Kimlball St., Bradford, MA 01835
7. Location where contents were disposed:
Stewarts Receivin Facility, 20 Sq. Mill St., Bradford, MA 01835
................. .......
See a have
I ign auller Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc- 11/12 System Pumping Record o Page 1 of 1
&.\ ash Con�rYlonWMassachusettsTorn of No��� '`r�do�Ie�''�'�'e of
-----------------------------
C t /Town of No-Andover
M Y
R 0 System Pumping Record
JUL 7 2026
W
t..
a Form 4
n a"
Af1f V4
Health Department
DEP has provided this form for use by local Boards 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. 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 key.
City/Town ----- State Zip Code
tab . System owner:
e2
Name
retr�n
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 ❑❑ Tight Tank ❑ Grease Trap
Yj other(describe):
4. Effluent Tee Filter present? [-] Yes Y No If yes, was it cleaned? Yes ❑ No
5. observed condition of component pumped:
5. System Pumped By:
AA C-A<aV
Name Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradfr,)rd,MA
,/,/,a �;()A -3 Cnx GAI
Signature of Hauler Date
Signature of Receiving Facility for attach facility receipt) ~� Date
t5form4.doc+1 1 11 2 System Pumping Record o Page I of 1
Town of Nod Andover
Commonwealth of Massachusetts
U ty/Town of No. Andover JUL 2026
System Pumping Record
Ilk -h Department
N, 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 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 0184,5
use the return .......
key. City/Town State Zip Code
2,. System Owner:
Same J jo#0
Name 1.
Address(If different from location)
City/Tolwn State Zip Code
Telephone Number
B. Pumping Record
1., Date of Plumping ...............-- 2. Quantity Pumped: o o
Date Gallons
3. Component: El Cesspolol(s) 0 Septic Tank E] Tight Tank El Grease Trap
ER Other
4. Effluent Tee Filter present? El Yes R No If yes, was it cleaned? 01 Yes E:1 No
5. Observed condition of component pumped:
0(1 All of this estimated
information is non-bindip nly at the um in Not,re, ponsiblf� be
_g.,valid o e time of. s and the date above.
6. System Pumped By:
/41 a San
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:
Stelwart's Receiv.ip�g Facility, So. Mill St., Bradford, MA 01835
0-1 Me's See above
Signature of Hauler Date
..................
Signature of Receiving Facility(or attach faci'lity receipt) Date
t5form4.doc,p 11/12 System Pumping Record•Page 1 of 1
Town of Nofth Andover
Commonwealth of Massachusetts
City/Town of No. Andover
U L
7 2026
Syste umpi,n ecord
Form 4
Health Departm ,
DP has provided this form for use by local Boards of Health. Other forms may be used, but the t
information must be substantially the same as that provided here. Before using this,form, check with your
local Board of Health to determine the for they use�. The System Pumpling Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping data in
accordance,with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not -No. Andover MIA 018,45
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
o
1. Date of Pumping Date___ 2. Quantity Pumped- Gallons
3. Component,: Cesspool(s) Septic Tank Tight Tank El Grease Trap
Other (describe): UA 9
4. Effluent Tee Filter present? 0 Yes No If yes, was it cleaned? � Yes F1 No
5., Observed condition of'component pumped:
All of this estimated
information is non-bin:d'ing, valid on!l resat the time of pumping, Not res � nd the data above.
6. System Pumped By:
IA4 A
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart"s Septic
Service, 58 So. Kimball St., Bradford, MA 0183,5
7. Location where contents were disposed:
Stewart's Receiving Facility, 20 So. Mill St., Bradford, MA 01835
a Y� z a A 0-S See above
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doco 1:1/12 System Pumping Record Page 1 of 1
9 k
Commonwealth of Massachusetts Town oj Noftn Andover
fit own of No. Andover
JUL
7 2026
__...
System Pumping, Record
Form 4 F1 o-,alth Depaftment
DEP has provided this form for use by local Boards of Health. Othe�r forms may be used, but t'he
information must be substantially the same as that provided he�re. 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 3101 CMR 15.351
A. Facility Information
Important:When
filling out forms 1. System Location-.
on the computer, �V (0 use only the tab
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
Idb 2. System Owner:
Same ce
Name
roue
Address if different from location)
.............
City/To,wn State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped
Gallons
3. Component: El Cesspool(s) Ej Septic Tank El Tight Tank El Grease Trap
9 1
Other(describe):
4. Effluent Tee Filter present? El Yes 0 No If yes, was it,cleaned? El Yes El' No
5. Observed condition of com orient pumped:
604 All of this estimated
-information is non-binding, vali d or ie time-of pu mpLing. Not ray onsible b�yqqq the date aboy
6. System Pumped By:
,M a ........
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service, 58 So. Kimball St.; Bradford, MA 01 35
7. Location where contents were disposed:
Stewart's Regeivipg Fac 2 0 Soy. Mill St., Bradford, MA 01835
144a
See above
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doce 11/12 System Pumping Recordo Page 1 of 1
Commonwealth of Massachusetts 101�11nof No�t,MdWer
C"ty/Town of No. Andover UL 0" 7 2026
>
0 System Pumping Record
00%
He
Form 4 alth De
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 determnine 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
accoirdance with 3101 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
1111111, 2. System Owner:
Same,
........ kj
Name
Address�if different from location)
......................
Cilty/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2, Quantity Pumped: G �_....._��._._....__
allons
3. Component: El Cesspool(s) El Septic Tank El Tight Tank El G�rease Trap
Other(describe): ... I V
4. Effluent Tee Filter present? El Yes No If yes,, was it cleaned? E] Yes F1 No
5. Observed condition of component pumped:
C.20 cl, All of this estimated
information is non-binding, valid o94 at the time of pumiping. Not 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 35
7. Location where contents were disposed:
Stewart's Re ceivin_Facility,._20 So,. Mill St., Bradford, MA 01835
..........
See above
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc,l 11/12 System,Pumping Record Page 1 of 1
"V
Commonwealth of Massachusetts
City/Town of No. Andover JUL 7 2026
,A, System Pumping Record
11'
Form 4 0 a Ith L)epa
rtMent
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 pumpling date in
accordance with 310 Cl R 151.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab ,25 / it 1;
.............
key to move your Address
cursor-do not No., Andover MA 0 1848
use the return,
ey City/Town State Zip Code ............
k .
2. System Owner:
;tab
Name
rate
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
X0
oil
��.__.._
Date . Qu anti
1. Date of Pumping 2 ty Pum p ed: Gallons
3. Component: El Cesspool(s) [:1 Septic Tank El Tight Tank El Grease Trap
Er'00,00" ther(describe):
4. Effluent Tee Filter present? 01 Yes o No If yes,, was it cleaned? M Yes El No
5. Observed condition of component pumpeld:
0
All of this estimated
information is non-bi 'jslid only at the time of pump�qcj. Not rqs�onsible he and the date above,
6. System Pumped B
Nar_6" 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 01835
-..........f..............f__
wpm
Se e above
...........
s,,G`,f6 r Date
..............
Signature of Receiving Facility(or attach facility receipt) Date
t5form!14.doco 11112 System Pumping Records Page 1 of 1
lOwn of Nod Andover
Commonwealth of Massachusetts
rM
z City/Town of No. Andover JUL 7 2026
System Pumping Record Health
1 rt t Form 4 tic en
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 31,0 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System L oc ation:
on:the computer,
use only the tab ...................... W�ffo
key to move your Address
cursor-do not No. Andover MA 01845,
use the return..........
key. City/T'own State Zip Code
*01 2. System Owner:
Same &Lke IN Joy
Name
low
Address(if different from location)
City/Town State Zip Code
Telephone Nlu�mber
B. Pumping Record'
1 Date of Pumping Z,C 2. Quantity Pumped:
Date Gallons
3. Component: Cesspool(s) El Septic Tank 0 Tight Tank 0 Grease Trap
Ell Other(describe): .............. .........
4. Effluent Tee Filter present? 0 Yes 0 No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
All of this estimated
information is non-binding, valid qqly.._..@t the time of puMping-, N.— nsib.le beyond the date above.
respol
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 Fac 20 So. Mill St., Bradford, MA 01835
See above
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doce 11112 System Pumping Record•Page 1 of 1
Town, of Noilh Andover
�L\ Commonwealth of Massachusetts
C
go"ity/Town of No., Andover JUL 7 2026
>
System Pumping Record
Ilk Form 4
Health Department
DEP has provided this form for use by local Board's 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 C MR 15.351.
A. Facil ity Information
Important:When
filling out forms 1 System Location:
on the computer,
use only the tab 3�; ( W il(ocj
key to move your Address
cursor-do not -No. Andover M,A 01845
use the return key. City/Town State Zip Code
2. System Owner: ............
Same
jo
Name
.................
Address(if different from location)
...........
City/Town State Zip Code
Telephone Number
B. Pumping Record
ie J
41/110
1. Date of Pumping .2 Quantity Pumped Gallons
3. Component: R Cesspool(s) E Septic Tank E] right Tank [:1 Grease Trap
000ii
010
0`
1010 ....... ")rll.;"'�",("',"' �
Other(describe): ......
4. Effluent Tee Filter present? El Yes 0001qo lif yes, was it cleaned? El Yes r_1 No
5. Observed,codition of component purnped:
All of this estimated
information is non-biqglpq.., valid only at the time ofbur ing. blot responsible be and the date above.
6. System Pumped By:
f, pe 10"
Nw
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:
Ste cart' Receivi,n.� acility, 20 So. Mill St., Bradford, MA 01835
See above
Haule Signature of r Date
......................
Signature of Receiving Facility(or attach facility receipt) Date
t5form4l.doco 11/12 System Pumping Record•Page 1 of 1
Town of Nofth Andover
Com monwealth of Massachusetts
L 7 2026
City/Town of No. Andover
System Pumping Record
Flealth DeLftaill,
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,
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
Etab 2. System Owner:
ta b a Same
ro
Name
LOW \4
Address if different from location,)
City/Town State Zip Code
Telephone Number
B. Pumping Record
Da z 4
1. Cute of Pumping ....... 2. Quantity Pumped:
Date Gallons
3. Component: E] Cesspool(s) El Septic Tank Djjrot" ight Tank 0 Grease Trap
d
E] Other(describe): ............... ----................
4. Effluent Tee Filter,present? El Yes tj(I No, If yes, was it cleaned? Yes 0�:116
5. Observed condition of compone it pumped:
All of'this estimated
information is.._.n M0-" IF ding, valid only at the time of um in . Not resonsible be and the date above.
6. Bysten umped By:
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's,Septic
,Service, 58 So. Kimball St., Bradford, MA 01835
7. Location where contents were disposed:
Stewart's Receiving Facility, 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
Town of NoO Andover
Commonwealth of Massachusetts
*ty/Town of No. Andover 2026
z
;A C1
JUL
IT
System Pumplong Record
Form 4
Health Department
DEP has provided thlis 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 CM R 15.351.
A. Facility Information
Important:When
filling out forms 1 System Location:
on the computer,
use only the tab ........ ... ...........
Icy to,move your Address _LAN,(/0 w -
cursordo not -No., Andover MA 01845
use the return City/Town
key. State Zip Code
21,
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 lumped Gallons——-......
3. Component: El Cesspool(s) El Septic Tank f:;h: Wight Tank F1 Grease Trap
E] Other(describe): .......
4. Effluent Tee Filter present? Ej Yes,1011"0'No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
All of this estimated
information i roA_g, valid on at the time of pumping. Not responsible be and the date above.
6. System Pumped Bot/.
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service, 58 So, Kimball St., Bradford, MA 01835
7. Location where contents were disposed:
Ste wart'�.Reeei $0. Mill St.,, Bradford, MA 01835
001
See above
nature of Ha �Wr,
Date
""00"
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc,, 11/12 System,Pumping Recordo Page 1 of 1
Commonwealth of Massach usetts Town of Nofth Andover
ity/Town, of No. AndoveriJUL
System Pumping Record
Al Form, 4 IN
Health "4,1
:tJ) nnt
5 l I
DEPI has pr ovi ui q pg
ded this form for use by local Boards of Health., Other forms may be ( d 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 City/Town State Zip Code
key.
2. System Owner:
tab
f1v 'j(9
Same
Name ..........
few ........---. --...........
Address if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pum' ped:
Date gallons
-
3. Component: El Cesspool(s) Ej Septic Tank R Tight Tank E] Grease Trap
E3r Other(describe):
4,. Effluent Tee Filter present? 0 Yes No If yes, was it cleaned? 0 Yes El No
5. Observed condition of component pumped:
J,a 61 All of this estimated
information is non-bind!pg_ valid' only at the time of_p pm ng. Not r n ible �e and the date above.
6. System Pumped By.,
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service, 518 So, Kimbal!l St., Bradford MA 01,835
T. Location where contents were disposed:
Stewart's Receiving Facility, 20 So. Mill St., Bradford, MA 01835
C 6vi ac;A.�.s See above
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doco 1'1112 System Pumping Record Page 1 of 1
Commonwealth of MassachusettsTovvn ; yI' No�
Andover
r City/Town of No.Andover
wf System Pumping Record JUL ' 2026
ti Form 4
-J/J Y1
�_ 5v a
,.,
P has provided this form for use by local Boards of Health. Other fW. def "441'
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 C M R 15,351.
A. Facility Information
Important:when
filling,out forms I. System Location:
on the computer, � r
use only the tab _ _ - f �,❑__❑ _ _
key to move your Address
cursor-do not
use the return key. City/Town State Zip Code
tab
2. System owner:
Name
J;A
Address(if different from location)
No-Andover MA
City/Town State Zip Code
Telephone Number
B. PumpingRecord2 1)
1. Date of Pumping 2. Quantity Pumped: 0 0
at
Gallons
3. Component: F-1 Cesspool(s) ❑ Septic Tank ; Tight TankT❑ Grease Trap
[� other(describe):
4. Effluent Tee Filter resent? E-1Yes No If es, was it cleaned?
p ❑� y Yes ❑� No
5. observed condition of component pumped:
6. System Pumped By:
AA CL
Name Vehicle license Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) DateT_
t5form4.doce 11/12System Pumping Record a Page 1 of 1