HomeMy WebLinkAboutCrusaders - Septic Pumping Slip - 350 HOLT ROAD 12/2/2024 Commonwealth of Massachusetts
_ City/Town of
System Pumping Record
y Form 4
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 —____.__..___._.._._....._._ ..__-.
key to move your Addres
cursor-do not ❑, r7 t / MA
use the return _ __� ___ __ .. _._... —_------___
key. CityfTown State Zip Code
2. System Owner:
__ _____._.._.__.__...__.__._.__-____._._-__..__..____.....__.._.________ ___.____...__.___...
Name —__--
"'`ry' SAME
Address(if different from location)
__.Zip.__C__.ode--___-------.
City/1 own State
Telephone Number
. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): _....___...._... ..__._._.._.._._..__-----__.......__._____..___.._._.__.___________-_ _.....
...__._..__.
4, Effluent Tee Filter present?Y Yes ❑ No If yes, was it cleaned? ❑Yes ❑ No
5. Observed condition of component pumped:
J All of this estimated
-infor is on-binding,_valid only at the time of.pum inr�Not responsible beyond the date above
6. Systte7Pu7d(�.�y:
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewart's Receivin _Facility 20-So.-Mill St., Bradford,MA 01835— —___.____ _- -.----_.__...___...__...__..._.............
See above
Sign
Date
See above
-- 31ature of Receiving FacAity(or attach facility reoeipt) Date
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