HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 149 SUMMER STREET 7/10/2025 IL\ Commonwealth of Massachusetts 1VVV[j at NOrth ArldOver
City/Town of AUG 112025
System Pumping Record
Form 4 Health Depart
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
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 CM R 15.351.
A. Facility Information
Important:"Oen
filling out for,ns 1. System Location:
on the computer, 14 q
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
return
Address(if different from location)
------------
City/Town State Zip Code
----------
Telephone Number
B. Pumping Record
1. Date of Pumping Quantity Pumped:
Gate Galons
3. Component: 7 Cesspool(s) Septic Tank 7 Tight Tank 7 Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes 7 No
5. Observed condition 0 component pumped:
G I
�m All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. Syste Name
ne 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 o-f-Receiving—Facility(—or attach facility receipt) Date
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