HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 23 WILLOW RIDGE ROAD 6/4/2025 O;r
*rth
., Commonwealth of Massachusetts ndaVer
City/Town of .". f,�A_ j r-
_ System Pumping Record
Form 4 IC
Fe
DEP has provided this form for use by local Boards of Health. Other forms may be usePVMOnt
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 Address
cursor-do not MA
use the return _
key. City/Town State Zip Code
2. System Owner:
Name
nrwn SAME
Address(if different from location)
City/Town State _ Zip Code
Telephone Number
B. Pumping Record
1, Date of Pumping Dat 2. Quantity Pumped: aiions ho(
3. Component: ❑ Cesspool(s) tiSeptic 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 p m component ed:
p �.�
All of this estimated
information is non-binding, valid-__ y at the time of pumping._Not responsible bey the date above,
6. System 13ped 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
See above
.......
Signature of Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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