HomeMy WebLinkAboutJuly 2026 Bake N Joy - Septic Pumping Slip - 351 WILLOW STREET 7/2/2026 Commonwealth of Massachusetts Town of'Noti Andover
M
City/Town of No. Andover
W
System Pumping, Kecord AUG 4 2026
,k
Form 4
At
DE P has provided this form for use by local Boards of Health. Other foRgAWDePMftent
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 CAR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, W,ffooa
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, 4ce jc
............... ........Name
Address if different from location)
City/Town State Zip Code
Telephone Number
B,., Pumping Record
G(C)
1. Date of Pumping 2. Quantity Bumped
Gallons
3. Component: El Cesspool(s) eptic Tank Tight Tank Grease Trap
EX Other(describe): ......
4. Effluent Tee Filter present? F� Yes Z No If yes, was it cleaned? E] Yes 0 No
5. Observed condition of component pumped:
� 005A All of this estimated
information is non-binding, valid only at the time qt_p_ymping. Not repoq,§i�!� bey the date above._
6. System Pumped By:
A .���������
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service, 58 So. Kimball St., Bradford, MA 01835
7. Location where contents were disposed:
Stew.art's Req��iying_F�����.o. Mill St., Bradford, MA 01835
See above
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.docs 11/12 System Pumping Recorde Page 1 of 1
I Town of NoWi Andover
Commonwealth of Massachusetts
Uity/Town of No. Andover
-4 2026
System Pumping Record AUG
Form 4
Health Deja ""n�nt
e qu t e
CEP has provided this form for use by local Boards of Health. Other forms may b e 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, CM R 15.351.
A. Facility Information
important:When
filling out forms 1. System Location:
on the computer,
use only the tab ..........
key to move your Address
cursor-do not No. Andover MA 01845
use the,return ...........
key. City/Town State Zip Code
2. System Owner:
111b
Same
.......... ....... Jou
Name
Run
Address(if different from location)
... .......
Cityflown State Zip Code
................
Telephone Number
B, Pumping Record
0 _� .._. W
1 Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: El Cesspool(s) 0 Septic Tank El Tight Tank El Grease Trap
[jd Other(describe):
4. Effluent Tee Filter present? El Yes �A; No If yes, was it cleaned? El Yes El No
5. Observed condition of component pumped:
2 ocu. All of this estimated
information is non-bLinqing, valid on.l at the time of pumping,. Not res on§lble 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 1835
7. Location where contents were disposed:
Stewart's Receiving Facility..,. 20 So. Mill St., Bradford, M,A 0:1835
1/ OL - 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
of North Andover
�L\ Commonwealth of Massachusetts
0 CI'lty/Town, of 6"4) AUG - 4 20126
I'Lo
System Pumping Record
Form 41
1-1;�Dalttl 1.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 Beard oaf 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, 01
use only the tab ............... '. _j
key to move your Address
cursor-do not NO AvLac V"�, MA 01860
use the return
key. City/Town State Zip Code
IV 2. System Owner:
K44)
Name
Address(if different from location!)
....... ........ ........ ........
City/Tolwn State Zip Code
Telephone Number
B. Pumping�, Record
1, Date of Pumping _ _....._ __
Date 2. Quantity Pumped:
Gallons
3. Component'. Cesspool(s) E] Septic Tank El Tight Tank 0 Grease Trap
.............
�7
4,11,11 r
jejjju ie��5, , ': '"' r, ,,.)�11(, C
Cf,1�11,, ------------
ED?'6ther(describe):
4. Effluent Tee Filter present? El Yes Ej No If yes,: was it cleaned? Yes No
5. Observed,,condition of component pumped:
1116" All of this estimated
,information is non-bindin.9, ,1,1 d only at the time of puTp±ng...Not re nsible be and the date above.
��Po
6. System, Pumped By,
..........
Ael
Name Vehicle License Number
J&S Development Corp., d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewart's Global Environmental, LL,C
20�o."Mill St. Bradford,, M'.,- 01835
00o
T— LK11 See above
0�'
mm.
Signature of Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doce 11/12 System Pumping Recorde Page 1 of 1
Commonwealth of Massachusetts Town of No�h Andover
City/Town of No. Andover
AUG -4 2026
>
System Pump'Ing Record
0 Form 4
Health Department
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this fermi, 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 114 days from the pumping date in
accordance with 310 CI VIR 15.351-
A. fi nformation
important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do,not No. Andover MA 01845
use the return
key. Cityrrown State Zip Code
16 tabu 2. System Owner:
Same (3' a L, 3o(,]
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: El Cesspool(s) El Septic Tank El Tight Tank El Grease Trap
S- I Other(describe) Uj, qe............
: W
4. Effluent Tee Filter present? 0 Yes No If yes, was it cleaned? E] Yes 0 No
5. Observed condition of component pumped:
I cda All of this estimated
information is nion-binding., v .1..id,,,,only at the time of pumpipg. Not re ..onsiblq eL_pd 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 disposed:
Stewart's Req�e vi l �� + ...-So. Mill St.,
9 0 YN W See above
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc,o 11112 System Pumping Recorde Page 1, of 1
Commonwealth of Massachusetts ,TOwn of Noi-th Andover
M
z
n dCity/Town of No. Andover AUG 4 2026
System Pumpnng Record
Form 4 Health DopartMent
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information rust be substantially the same as that provided here. Before wing 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
ac cordance with 310 CIVIR 15-351.
A. Facility Information
Important:When
fill'ing out forms 1 System Location:
on the computer,1
use only the tab
key to move your Address
cursor-do not No. Andover MA 0:1845
use the return ......
key. City/Town State Zip Code
2. System Owner:
Same
Name
affn
Address if different from location)
City/Town State Zip Code
.............. ......
Telephone Number.
B. Pumping Record
-07
1., Date of Pumping ...._�.�.
Date 2. Quaniti'ty Pumped:
Gallons
3. Component: F1 Cesspool(s) El' Septic Tank E] Tight Tank El Grease Trap
Other(describe):
4. Effluent Tee Filter present? 0 Yes No If yes, was it cleaned? Yes [:] No
i
5. Observed condition of complonenit pumped:
IN
1008 All of this estimated
information is non-bipdLinq, valid only at the..time of pu pip.g. Not.jesponsible beyopo.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 disposed:A.
Stewart's Receiving1=acililw So, Mill St., Bradford, MA 01835
/4-
See above
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc,o 11/12 System Pumping Record Page I of 1
Commonwealth of Massachusetts n of NOrth Ando,,
City/Town of No. A,n�dover AUG
--4 22
.f .�
t
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 p,umpi'ng date in:
accordance with 310 CM R 15.351.
A. Facility Information
Important:When
filling out forms, 1. System Location'.
on the computer, 00-
use only the tab 35
key to move your Address
cursor-do not No. Andover MA 01845
use the return "I'll"1 - --- —
key. City/Town State Zip Code
*Clab 2. System Owner:
Same
Name
Address if different from location,)
City/Town State Zip Code
Telephone Number
B1. Pumping record
1. Date of Pumping ._ ..._ _.
Date 2. Quan,tity Pumped: Gallons
3. Component: El Cesspool(s) Se,pt,i'c Tan,k Ej Tight Tank 0 Grease!Trap
Other(describe): ..........
4. Effluent Tee Filter present? El Yes No If yes, was it cleaned? 0 Yes El No
5. Observed condition of component pumped:
cip
All of this estimated
information is nion-binding, valid only at the tim.e.of urn iin . Not T pop ible beyq�qqjhe date above.
6. System Pumped By:
a.
J11vot-9 00
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 Receiving.facilit , 20 So. Mill St., Bradford, MA 01835
See above
.............--.-......
Signature of Hauler Date
Signature of Receiving Facility for attach facility receipt) Date
t5form4.doco 11/12 Systemi Pumping Records Page 1 of 1
Commonwealth of Massachusetts Town of NO*Andover
City/T'own of No., Andover AUG 4
2026
System Pumping Record
Foirm 4
110altti 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 CI R 15.,351.
A. Facility Information
Important:When
filling out forms 1 System Location:
on the computer,
use only the tab
key to move your Address,
cursor-do not No. Andover MA 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. Pum ping Recur d
1e7
1. Date of Pumping Date 2. Quantity Pumped': -Gallons
3. Component: El Cesspool(s) 0 Septic Tank Ej Tight Tank El Grease Trap
Other(describe): ........
4. Effluent Tee filter present? E] Yes E9 No, If yes, was, it cleaned? [:1 Yes No,
5. Observed condition of component pumped:
3 06g, All of this estimated
information is nonbindinig, valid only at the time of pum Not responsible be and the date �bove.
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 Receiving Facilit 20 So. Mill St., Bradford, MA 01835
y ...
a S See above
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doce 11112 System Pumping Recorde Page 1 of 1
Town of No�h Andover
Commonwealth of Massach usetts
it own of No. Andover AUG -4 2026
0
System Pumping Record
Form 4
Health [Department
DEP has provided this form for use by local Boards of Health. Other forms m ay 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. iir Information
Important:When
filling out forms 1, System Location:
Can the computer, 35 /
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
"Y Name
TWA
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped G Jf-I Q-n—s-
3. Component: E] Cesspool ) El Septic Tank 0 Tight Tank El Grease Trap
Other(describe): Aj
4. Effluent Tee Filter present? 0 Yes EA No If yes, was it cleaned? El Yes 0 No
5. Observed condition of component,pumped:
All of this estimated
information i's non-bindle , valid only at the time of urn in responsible beyqqq 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 disposed:
Stewart's Receiving Facility, 20 So. Mill St., Bradford, MAC 1 35
..........
V%.ts See above.
Signature of Hauler Date ..__................
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doce 11112 System Pumping Record o Page 1 of 1
Town f Nofth Andover
Commonwealth of Massachusetts
"""""ity/Town of No. Andover 2026
T M
System Pumping Record
Form 4 D e 111
Ar
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substanitially the same as that provided here. Before using this fermi, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Bard of Health, or other approviing authority within 14 days from the pumping date in
accordance with 310 CM R 1 5.35 1.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the compulter,
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:
11%Gtab I
'Same
Name
teun
Address(if different from location)
City/Town State Zip,Code
.............
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Ghl'hens
...
3. Component: El Cesspool(s) E:1 Septic Tank El Tight Tank KOOGrea,se Trap
El Other(describe):
4. Effluent Tee Filter present? 0 Yes X'N' If yes, was it cleaned? [:1 Yes lsi�o
eNn
5. Observed condition ofcomponIC7 1 1t ump
All of this estimated
information is/KbnAindin valid on at t ,e time of pump��. Nqot�res onsible beyond the date above.
6. Syst m Pumped By.-
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service, So. Kimball St., Bradford, MA 01835
7. Location disposed:
�V � ktf,-:ga--S-o. M i I I radford, MA 0 1835
o---�ewart's Rece!l���ilillillillillIllillil1,1���l�����i F
See above
Signature of Hauler Date
............
Signature of Receiving Facility(or attach facility receipt) Date
t5form,4.doco 11/12 System Pumping Record Page 1 of 1
Town of N l
Commonwealth of Massachusetts -4 2026
AUG
City/Town of No. Andover
System gtcn
t
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 uls,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 3,10 CMR 11 5.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on,the comp�uter, (6 tv
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
10 tab 2. System Owner:
Same
Name
Run
Address if different from location)
............
City/Town State Zip Code
Telephone Number
B. Pump-Ing Record
C.0001
1., Date of Pumping Date 2. Quantity Pumped: Ga,I-I,on I s
3. Component: El Cie ss,polol(s) 0 Septic Tank E] Tight Tank Z5�ll`real Trap
El Other (describe): ..........
-11--
4. Effluent Tee Filter present? F1 Yes;X-'ONo If yes, was it cleaned? El Yes 2�1 Cr
5. Observed condition of co nt pumped:
z!>1 r, cl�>
I All of this estimated
information mITi non-bind' valid only,.at the time of_puTp tl�otj�sponsible beyond the data above.
s
6. System mped By:
Name Vehicle icense 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:
Ste5FBradford, MA 0 1835
0 so. mill St.
See above
9fle er Date
S,ig n:ature of Receiving Facility Car attach facility receipt) Date
t5form4.doc,, 11/12 System Pumping Recorde Page 1 of 1
Commonwealth of Massachusetts Towii of NoM Andover
Clity/Town of No. Andover
AUG - 4 2026
__ _..
System Pumping Record
Form 4
Health Department
[CEP 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 No. Andover MA 01845
key. City/Town State Zip Code
tdb 2. System Owner:
Same
Name
teen
Address if different from location)
.............
City/Town State Zip Code
Telephone Number
B. Pumping; Record
1. Date of Pumping 2,. Quantity Pumped: 000
Date Gallons
3. Component: L Cesspool(s) El Septic Tank [:1 Tight,Tank ® Grease Trap
E` Other(describe): S I V Ag-C, ............-.......
4. Effluent Tee Filter present? 0 Yes, R No If yes, was it cleaned? El Yes Ej No
5. Observed condition of component pumped:
'All of this estimated
-information is non-binding,_yalid only at the time of.pumping. Nptlesponsible b�yqnd the data 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 disposed:
Stewart Receiving Facilit 20 So. Mill St.,, Bradford, MA 01835
yl
-S See above
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt)ITm
Date
t5form4.doc,o 11/12 System Pumping Record Page 1 of 1
Commonwealth of Massachusetts IUWn of Nodh Andover
C i own of No. Andover
System Pumping Record AUG 4 2026
Form 4
DEP has provided this form for use by local Boards of Health. Other f4�"� c 10 bPARP bU%nt
information miust 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. Facil ity I nformation
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab ..........
key to move your Address
cursor-do not -No. Andover MA 01845
use the return key. City/Town State Zip Code
2. System Owner: jo
Same
.......................
Name
few
Address(if different from location)
City/Town State Zip Code
Tel'e hone Number
B. Pumpin rd
1. Date of Pumping .................. 2. Quantity Pumped:Date Gallons
3. Component: Cesspool(s,) F1 Septic Tank El Ti ht Tank 0 Grease Trap
�l, UOther(describe): ...................... ......
4. Effluent Tee Filter present? 0 Yes [jd No If yes, was it cleaned'? Yes No
5. Observed condition of component pumped:
AlIl of this estimated
Information is non-bind'iN, valid only a,t the time of pumpiq,(L Not responsible beTo9q.the date above.
6. Sy tern Pumped By:
Cj
............ .......
Name Vehicle License Number
JI&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 Recorde Page 1 of 1
Commonwealth of Massachusetts W I own af No�h Andover
City/Town of No. Andover
- 4 2026
System Pumping Record AUG
Form 4
11o,alth De ent
CEP has provided this,form for use by local Boards of Health. Other forms may be usep�,, ,ult Ttle
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 Heal'th, or olther approving authority within 14 days from the pumping date in
accordance with 310 CAM R 15.351.
A. Facility Information
Important:When
filling out forms 1. System, Location,
on the computer,
use on!ly the tab 01(1110
key to move your Address
cursor-do not -No. Andover MA 01 84�5
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.1 Pumping Recoro
-7,
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: F1 Cesspool(s) Septic Tank Tight Tank Grease Trap
iww
1", 111- L01010
00
Other(describe):
4. Effluent Tee Filter present? � Yes E3,0'&o If yes, was it cleaned? Ej Yes Ej No
5. Observed gondition of component pumped:
10'
All of this estimated
information is non-bip4(!jg_,_.vali'd o ilk the time..of pumping. Not responsible beyqpd 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 disposed:
.Stewart's ReqeLiy�in_g Facility, 20 So. Mill St., Bradford, MA 01835
...........
.0100�
See above
............ 10
Signature of Hauler"' Date ............
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.docs 11/12 System Pumping Record Page I of I