HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 CHRISTIAN WAY 7/8/2025 rOW17 of jVort
� "'` Commonwealth of Massachusetts hAn�,OVer
City/Town of -
�° System Pumping Record JUG 2025
Form 4 Health
DEP has provided this form for use by local Boards of Health. Other forms may be u % t 00,/.,
information must be substantially the same as that provided here. Before using this form, check with'four
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:
t�
Name
7B SAME
Address(if different from location)
_._. ---- -- --- --- ._..... - --
City/Town State Zip Code
.....
Telephone Number
B. Pumping Record --
1. Date of Pumping Date 2. Quantity Pumped: G -ins
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): .... - -
4. Effluent Tee Filter present? ❑ Yes 0,No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed con ti of CORD; anent pumped:
All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
& System Pumped 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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