HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 210 RALEIGH TAVERN LANE 9/22/2025 Town
Commonwealth of Massachusetts
City/Town of
OCT 6 2025
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used 144le
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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, —)
use only the tab r >V
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code
2. System Owner:
zrk::�)c—cm
Name
ream ,
Ad-dress(if—different from location)
City/Town St—ate Zip—Code
Telephone Number
B. Pumping Record
67
1. Date of Pumpin g =9j a�azlx--
Date 2. Quantity Pumped: Gallons
3. Component: Cesspool(s) Septic Tank L—
1 7-1 Tight Tank Grease Trap
' Other(describe):
4. Effluent Tee Filter present?
.] Yes I No If yes, was it cleaned? Yes No
5. Observed condition of c mponent pumped:
6. System P
0
Name
Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 SoMill St.,Bradford,MA
Signature ofHaul6—r 5—ate
Signature—ofReceivTn—gFacility(or—attach facility
t5form4,doc-11/12
system Pumping Record=Page I of I