HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 249 REA STREET 10/6/2025 Commonwealt f M s chusetts Wn
City/Town of ,U
System Pumping Record OCT 2025
❑s Form 4
f
DEP has provided this form for use by local Boards of Health. Other forms may E ms , t4h,e
information must be substantially the same as that provided here. Before using this form, c 644ith 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 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:
tea
Name
return
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record _
1. Date of Pumping t 2. Quantity Pumped: ~T
p g Date y p G�ons
3. Component: ❑ Cesspool(s) septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? [ es ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condi ion of co ponent pum ed:
L160A,;�� L-6 All of this estimated
information is non - he, valid only at the tl e of pumping. Not responsible beyond the date above.
6. syst ump By:
&,.,(
Name Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewart's Global Environmental, LLC
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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