HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 61 ABBOTT STREET 5/6/2025 Commonwealth of Massachusetts Town of
City/Town ofndO ��
System Pumping Record SUN 4 2025
4. ❑ Farm 4
DEP has provided this farm for use by local Boards of Health. Other farms ay m 3
information must be substantially the same as that provided here. Before using this farrnche ftour
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, r `� .
use only the tab I P, .w > µ " ...
key to move your Address
cursor-do not MA
use the return -- -- - - — --
key. City/Town State Zip Code
t�
2. System Owner:
rcA
Name
µ
SAME
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: __
Date 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:
noo All of this estimated
information is non-binding, valid at the time of pumping. Not responsible beyond the date above.
6. System P d By:
- -
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewart's Receiving Facility, 20 So. Mill St., Bradford, MA 01835
11
See above
Signature of Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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