HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 453 FOREST STREET 1/5/2023 Commonwealth of Massachusetts RECENED
W City/Town of JAN 0 5 2023
System Pumping Record Or NOR(H ANDDvER
Form 4 tG�JN TN DEPARTMENT
M
NEAT:
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,
use only the tab �'f _7 7 ��—
key to move your Address
cursor-do not f� ✓l MA
use the return
key. Cify/Town State Zip Code
dr_ 2. Owner:
,� System
Name
re2m
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dad -6 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.-
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 D opment Corp. d/b/a
Stewa 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
Signature of Hauler Date
Same
Signature of Receiving Facility(or attach facility receipt) Date
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