HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 261 CARLTON LANE 7/3/2025 [ Commonwealth of Massachusetts 7"owrr p NO*
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System Pumping Record AUG 11`. Y � � 2025
h Form 4
DEP has provided this form for use by local Boards of Health. Other forms may u � pp
information must be substantially the same as that provided here. Before using this form, check witour
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 cC 1 _ �TCJ CI YV2
key to move your Address
cursor-do not MA
use the return
key. City/Town State Zip Code
2. System Owner:
Name
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:
t: " All of this estimated
information is non-binding, valid on)y at the time-of pumping. Not responsible beyond the date above.
�tam ed B y 6. ste f
�Mw �
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
tewart s eiving Facility, 20 So. Mill St , Bradford, MA 01835
See above
gn Hauler date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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