HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 175 GREAT POND ROAD 1/5/2023 Commonwealth of Massachusetts
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= City/Town of
System Pumping Record BAN
Form 4 TOWNOF
NORrH TMENT R
M , HEAt.1'H DEPAa
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, -ram/ ! 5 G eod use only the tab __��
key to move your Address
cursor-do not MA
use the return
key. City/Town State Zip Code
2. System Owner: n
Name
ream
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping pate - 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 kNo
5. Observed condign of c7onent pumped:
Obsery ti ns are driver's o inion based on what he sees at time of pumping on the date above.
6. System mpel�:L J
1,
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:
Stewart's Global Environmental, LLC, 20 So. Mill St., Bradford, MA 01835
Same
---- Date _ - -
Same
Signature of Receiving Facility(or attach facility receipt) Date
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