HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 38 FARNUM STREET 1/5/2023 RECEIVED
Commonwealth of Massachusetts
= City/Town of
J AN 0 5 2023
System Pumping Record 7o_�Ir��,rl�o PARTM EN
Form 4 HEn4T
M
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, C �'.� r
use only the tab 3 D �-Z91 Um
key to move your Addr se s
cursor-do not MA
use the return key. City/Town State Zip Code
2. System Owner:
B cam/ aU(Df nn _
—
Name
�enm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Da 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): —
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed,condition of component pumped:
G�d6o
Observations are driver's opinion based on what he sees at time of pumping on the date above.
6. System Pumped By:
Name Vehicle License Number
J&S Development Corp. d/b/a
Stewart's Septic 58 So. Kimball St., Bradford,MA
7. Location where contents were disposed:
Stewar s Global Environments LC, 20 So. Mill St., Bradford, MA 018335
Same / v
Signature of Hauler, Date
_Same _
Signature of Receiving Facility(or attach facility receipt) Date
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