HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 48 HAWKINS LANE 1/5/2023 � Commonwealth of Massachusetts
W City/Town of Al 20oLzr
System Pumping Record o�tioti3 ��
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Form 4 M
DEP has provided this form for use by local Boards of Health. Other forms R��gj�@�, but the
information must be substantially the same as that provided here. Befe fells form, check with your
local Board of Health to determine the form they use. The System Pumpir 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 7(�/'�4
key to move your Address
cursor-do not MA
use the return Cityrrown State Zip Code
key.
2. System Owner:
� T�4 V m
Name
Address(if different from location)
CitylTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Weptfic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes (2" No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
Goo 14
Observations are driver's opinion based on what he sees at time of pumping on the date above.
6. System Pumped Byy
`J �eS v
Name Vehicle License Number
AS Development Corp. d/b/a
Stewart's Septic 58 So. Kimball St., Bradford,MA
7. Location where contents were disposed:
Stewao Global Environmeatal, LLC, 20 So. Mill St., Bradford,, MBA 0183`5
C_ 1Y' Same -
Signature of Hauer Date
Same
Signature of Receiving Facility(or attach facility receipt) Date
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