HomeMy WebLinkAboutAugust 2026 Bake N Joy - Septic Pumping Slip - 351 WILLOW STREET 8/4/2026 Commonwealth of Massach usetts Town Of Jvorttl 4&% ,
1160,ver
City/ dov
Town of No. Aner
SEP
System Pumping Kecord 32
Form 4
Af
Health Aft.
Uevqt,
DEP has provided this form for use by local Boards of Health. Other forms may be use
information must be substantially the same as that provided here. Before using this form, check welig our
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,,
oi
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 ...........
2. System Owner:
ame 011ke
Name,
reties
tumn
F—A ..................
Address if different from location)
City/To n State Zip Code
..........
Telephone Number
B. Pumping Recoird 1�
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: E Cesspool(s) El Septic Tank El Tight Tank El Grease Trap
4Z4 L11 -iCA"-00
�Other(describe).
4. Effluent Tee Filter present? E] Yes BeN�o If yes, was it cleaned? El Yes 0 No
5. Observed condition of co nent pumped:
7, All of this estimated
information is non-binding, valid only_q�tthe time of um in Not re§gqnsible beyond the date above.
6,. System Pumped By:
tl
100
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 Facilitv, 20 So. Mill St., Bradford, MA 018,35
See above 2
.............................. .......
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 Town of Noti Andover
00*'ity/Town of No. Andover
S E P 3, 2 0 2 6
System Pumping Record
Form 4
Health Department
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information mulct 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 withilini, 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, VV (0 tlo
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:
VQ I I - VV
Same ke
Name
W
Address(if different from location)
City/T own State Zip Code
Telephone Number
B, Pumpoin,g Record
1. Date of Pumping 2. Quantity Pumped: V/
Date gallont
-6j
3. Component: F1 Cesspool(s) 0 Septic Tank El Tight Tank Z**--Crease Trap
E] Other(describe):
4. Effluent Tee Filter present? 0 Yes If yes, was it cleaned? El Yes 0 No
5. Observed condition of component pump
100�
I?
All of this estimated
information is non-bincling, vaffdonl'La�t�e time of_p4MpAn . Not ray n sibile 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. Kim�ball St., Bradford,, MA 01835
7. Location where co e s were disposed:
I St L a 's Receivi 9 F ilit , 20 So. Mill St., Bradford, MA 01835
See above
Si e of Hauler Date
Signature of Receiving Facility(or atta ch facility receipt) Date
t5form,4.doc-, 11/12 System Pumping Recordo Page 1 of 1
TOM of NOdh Andwer
Commonwealth of Massachusetts
City/Town of N . Andover
SEP
SQ0 System Pump"Ing Record 2026
Form 4
Health rw%
DEP has provided this form for use by local Boards of Health. Other forms mayypwo, m(tat
information must be substantially the same as that provided here., Before using this form, check with your
local Board of Health to determ,ine 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
filliln,g out forms 1. System Location:
on the computer, ol
use only the tab 0(A
key to move your Address
cursor-do not No. Andover--
key NA 01845
use the return City/Town State Zip Code
y.
2. System Owner:
tab
Same
............ ..................
JA N-a me
;
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date G !Ilons
3. Component: El Cesspools) El Septic Tank F1 Tight Tank yr Grease Trap
El Other(describe): .......
4. Effluent Tee Filter present? [I 'Yes)4 No If yes, was it cleaned? El Yes R No
5. Observed condition of component plumped'.
All of this estimated
information is non-Oi �td��, valid' o.nl at the time of pump Not resp nsible bey nd 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 018351
7. Location where cont s ere disposed-,
wart s eivin , Fa My, 20 So. Mill St., Bradford, MA 01835
See above
S, tur Ha er Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc4- 11/12 System Pumping Record e Page 1 of 1
Commonwealth of Massachusetts Town of Nollh Andover
Z City/Town of No,. Andover
M SEA3 2026 ,
System Pumplmng Record
S, Form 4
Ar S14
14 c-
Pi t,
DEP has provided this form for use by local Boards of Health. Other forms may be'usPdagM
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. Faci l ity Information
Important:When
filling out forms 1. System Location:
on the comr puter, W
use only the tab ...........
key to move your Address
cursor-do not No., Andover NA 01,845----
use the return __.
key. City/Town State Zip Code.
2. System Owner:
Same
Name
few
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: F-1 Cesspololl(s) El Septic Tank E:1 Tight Tank F1 Grease Trap
Other(describe);:
4. Effluent Tee Filter present? El Yes No If yes, was it cleaned? 0 Yes Ll No
5. Observed condition of component pumped:
All of this estimated
information is non-binding, valid on..ly at the time of pumping. Not rep onslble be and the date above.
6. System Pumped By:
ase 0!N -—.....M.. ..........
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:
S,tewart's Req�vin Facilit �.O Sol. Mill St., Bradford, MA 01835
.......................
See above
Signature of Hauler Date
Signature of Receiving Facilit y(or attach,facility receipt) Date
t5form4.doco 11/12 System Pumping Record Page 1 of I
Commonwealth of Massachusetts TOwn of Nod A,do,,,%
ity/ own of No. An�dovr
; SEP
2026
ziystem Pumping Record
Form 4
At DepartMetit
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' IR 15.351.
A. Facility Information
Important:When
filling out forms 1 System Location:
on the computer, tt, Ue W
use on ly the tab
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/T'own State Zip Code
key.
2. System Owner:
tab
Same J 0
Run Name
Address if different from location)
City/Town State Zip Code
Telepho e umber
B. Pumping Record
1. Date of Pumping ........... 2. Quantity Pumped:
Date Gallons
3. Component: E] Cesspool(s) 0 Septic Tank El Tight Tank El Grease Trap
�4 Other(describe): -S I U d 9
4. Effluent Tee Filter present? El Yes R No If yes, was it cleaned? [:1 Yes, El No
5. Observed condition of component pumped:
All of this estimated
information is non-binding, valid only at the time of um in Jot responsible beyond the date above.
6. System Pumped By:
S ON*)
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"mnq Facility, 2P.....So. Mill St., Bradford, MA 01835
Y) See above
Signature of Hauler Date
Signature of Receiving Facility(or attach,facility receipt) Data
t5form4.doco 11/12 System Pumping Records Page 1 of 1
Commonwealth of Massachusetts TOM of'Nofth Andover
0-A Ulty/Town of: No. ndover 3 2026
System Pumping Record
Form 4 Health Department
At
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 Purnping 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 cornputer,1
use only the tab
key to move your Address
cursor-do not No. Andover NA 01845
use the return key. City/Town, State Zip Code
2. System Owner:
V Gfe b Same jow
Name
A
few
.................
Address If different f rom location)
. .. ......
City/To .......
wn State Zip Code
................
Telephone Number
B. Pumping Record
1 Date of Purnping Date .......... 2. Quantity Pumped: -G a I I o n s
3. Component: Cesspool(s) E] Septic Tank M Tight Tank Grease Trap
V" el
E� Other(describe): �t ............. .........
4. Effluent Tee Filter present? 0 Yes No If yes, was it cleaned? Yes F] No
5. Observed condition of component pumped:
All of this estimated
information is non,-binding, valid onI time of um in ponsibile beyond
y at the Not res 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�LyLing_fq Facility, �O...So. Mill St., Bradford,, MA 01835
See above
Signature of Hauler Date
...........
Signature of'Deceiving Facility(or attach facility receipt) Date
t5form4.doco 11/12 System Pumping,Record Page 1 of 1
Commonwealth of Massachusetts Town of N'o�h Andover
i wn of No. Andover
S E 3 2026
System Pumpaing Record
Form 4
Health Depaftrpent
DEP has provided this form for use by local Boards of Health. Other forms may be used, bu
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. Facil ity Information
Important:When
filling out forms 1. System Location:
on the computer, (0
use only the tab
key to move your Address
cursor-do not No. Andover MA 01845.......
use the return City/Town State Zip ode
key. C
tab 2. System Owner.-
Same
Name
On
Address(if different from location)
..........
City/Town State Zip Code
Telephone Number
B. Pumping Recor'd
1!. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: El Cesspool(s) Septic Tank Tight Tank Grease Trap
Other(describe): o g
4. Effluent Tee Filter present? F-1 Yes [0 No If yes, was it cleaned? 0, Yes E No
5. Observed condition of component pumped:
All of this estimated
Not re
information is non-binding, valid qop at the time of puMp sponsi.ble beyond the date above.
Nc_
6. System Pumped By:
OL
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' Rege yvjp_g�acility, 20, Sobill St., Bradford, MA 01835
'14mca-A 'See above .........
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doce 11112 System Pumpi:ng Record Page 1 of 1
lvwn of North 4ndover
Commonwealth of Massachusetts
SEP 3 2026
City/Tolwn of No. Andover
System Pumpoing Record '10alth Departj�.0-11
Form 4
At
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 CIF 15.351.
A. Facility Information
Important:When
filling out forms 1, System Location:
on the computer,
use only the tab V,v
key to move your Address
cursor-do not No. Andover MIA 0:1845
use the return ...........
key. City/Town State Zip Code
Ido 2. System Owner:
Same 4
Name
tow
Address(if different from!location)
........... ................
City/Town State Zip Code
Telephone Number
B. Pumpling Record
-Z 7 62
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: El Cesspools),., E] Septic Tank El Tight Tank El Grease Trap
Lf
61f
Other(describe):
4. Effluent Tee Filter present? El Yes io If yes, was it cleaned? F1 Yes 0 No
5. Observed condition of component pumped:
All of this estimated
.information is non-binding, valid only at the time of pum�g. 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 01835
7. Location where contents were disposed:
,Stewart's Receiving Facility, 20 So. Mill St., Bradford, MA 01 35
See above
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doco 11112 System Pumping Records Page 1 of 1
Town of NOrth Andover
Commonwealth of Massachusetts
City/Town of No. Andover SEP 3 2026
....... System Pumping, Record
Form
Ar 4
14 Healtir-1 D 4"1 111 111 e 1)
CIVh 111,
II J1
: ii
I E i *W
DiEP has provided this form for u1se by local Boards of Health. Other forms may bile used, b�it t
information must be substantially the same as that provided here. Before using, this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping data in
accordance with 3101 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., Andoiver—.— .............. NA 01845
use,the return City/Town State, Zip,Code
key.
2. System Owner.:
I ctj IF
Same
.................... ............ ..........
remName
Address(if'different from location)
City/Town State Zip Code
Telephone Number
B., Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons ------
I
3. Component: F-1 Cesspool(s)l Septic Tank Ell Tight Tank El Grease Trap
707
(describe):
4. Effluent Tee Filter present? [:1 Yes R l`" o if yes, was it cleaned? E:1 Yes E:1 No
5. Observed c ndition of component pumped:
All of this, estimated
information is non-biq JN, val..id.only at the time of um ping. Not s onsible beyond the date above.
...........
6. System Pumped By:
M.
ell
Na me Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service, 58 Sol. Kimball St., Bradford, MA 01835
7. Location where contents were disposed:
Stewart Reicei'vina,' Facility �o �o. Mill St., Bradford, MA 018351
-si e'lli"S
0, See above
Signature of Hauler Date
Signature of Receiving Facility for attach facility receipt) Date
t5form4.doct,11/12 System Pumping Record Page 1 of 1
Town of NoO Andover,
S.'\ Commonwealth of Massachusetts
S 3 2026
City/Town of No., Andover
System Pumping Record
Health pit
Foirm 4
At
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 Pumpling 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 compulte,r,
use only the tab ..............
key to move your Address
cursor-do not No. Andover, MA 01845
use the return key. City/Town State
;dip Code
ij� tab 2. System Owner:
Same te
Name
rem
Address(if different from location)
City/Town State Zip Code
----—-------
Telephone Number
B. Pumping Record
PON
1., Date of Pumpling 2. Quantity Pumped: C)
Date Gallons
3. Component: Ej Cesspool(s) E:1 Septic Tank El Tight Tank E] Grease Trap
2'Other(describe): 75" 0
4. Effluent Tee Filter present? 0 Yes /o If yes, was it cleaned? Yes Ej No
5. Observed condition of component p�um;pe
a,0
All of this estimated
,information is non-bindi..pq, vq.11i6jnly at the time of pum In N.9jtq§pon�Jbile be and the date above.
6. S�ysteroped 1311:
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 Facility, g_p So. hill St.J.-Bradford, MA 01835
See above
na of Mauler 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 Nofth Andover
City/Town of No. Andover SEP 3 2026
System Pumping Record
Af Form 4 Health Department
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 3110 CMR 15.351.
A. it l ity Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
Ivey to move your Address
cursor-do not No., Andover MA 01845
use the return ......
key. City/Town State Zip Code
2. System Owner:
V
Same
Name
rota
Address if different from location)
City/Town State Zip Code
..............
Telephone Number
B. Pumping Record
1. Date of Pumping Date' 2 Quantity Pumped: Gallons
I Component,., Cesspool(s) 0 Septic Tank E] Tight Tank 0 Grease Trap
Other(describe):
4. Effluent Teel Filter present? Ej Yes [0 No If'yes, was it cleaned? El Yes 0 No
5. Observed condition of component pumiped:
6 6
All of this estimated
-information is non-binding, valid on ...at the time�ofpq ing. Not responsible be end the date above.
_y
6. System Pumped By:
1/11 6L 10
............
Name Vehicle License Number
J'&S Development Corp., d/b/a Stewart's Septic
-Service, 58 So, Kimball St.,, Bradford, MA 01835
7. Location when contents were disposed:
Stewart's Recejy!_r�q.F.acility, 20 So. Mill St.1 Bradford, MA 01835
See above
Signature of Hau'ler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc9 11/12 System Pumping Record Page I of I
Town f 1`qofth Andover
Commonwealth of Massachusetts
TV SEP 3 2026
14 "'ty/Town of No. Andover
Iz
0
SNsteml Pumpi ng Record
y
F,
Form 4 Heallh� Department
f t'q
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, Facility Information
Important:When 1,
filling out forms, System Location:
on the computer,
1 fA,)
use only the tab
key to move your Address
cursor-do not No. Andover— M A 01 84�5
use the return key.' City/Town State Zip Code
2. System Owner:
Same J-0c
.. _
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
I
3. Com []ponent: E] Cesspool(s) 0 Septic Tank E] Tight,Tank Grease Trap
S 1
Other(describe):
4. Effluent Tee Filter present? El Yes EK No If yes, was it cleaned? 0 Yes 0 No
5. Observed condition of component pumped:
All of this estimated
information is non-binding, valid only at the time of pmumping. Not repponsible, 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 01835
7, Location where contents were disposed:
Stewart'�s Receiving F act li 20 So. Mill St., Bradford, MA 01835
__-_/91 A 9 cy'(1 See above
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5fo,rm4.doce 11/12 System Pumping Recordo Page 1 of 1