HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 295 FOREST STREET 6/20/2025 Commonwealth of Massachusetts Town ofNOr
x City/Town of ..
JUL 8
System Pumping Record 2025
Form 4
DEP has provided this farm for use by local Boards of Health. Other forms may be used, but fhgp4a/"tr,"t
Information must be substantially the same as that provided here. Before using this farm, check with your
local Board of Health to determine the farm 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: "f
on the computer, A _
use only the tab
key to move your Address
cursor-do not MA
use the return key. City/Yawn State Zip CodeVQ -
2. System Owner:
Name
ern SAME
Address(if different from location
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ,Date _ 2. Quantity Pumped: dons
3. Component: ❑ Cesspool(s) (Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): - -
4. Effluent Tee Filter present? ❑ Yes Ez No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component 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:
�,,dl A1a .._..
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., Bra . ---__ ......_.
1� �� sti +�'�` See above
Signature of Hauler Date
See above
-- _.. .._._... ...-.
Signature of Receiving Facility(or attach facility receipt) Date
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