HomeMy WebLinkAboutTavern on High Grease Trap - Septic Pumping Slip - 18 HIGH STREET 10/6/2025 Commonwealt of assachusetts Town forth
x r City/Town of
An
w" System Pumping Record OCT 6 2025
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may b ,f
information must be substantially the same as that provided here. Before using this form, checth 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
r�
2. System Owner:
m _ 1
N 11 ame
remm
Address(if different from location)
City/Town State Zip Code
. .... _
Telephone Number
B. Pumping Record
1. Date of Pumping W _.-__.. 2. Quantity Pumped: 1-34J
DateGallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank kGreaso Trap
Other(describe): ......
4. Effluent Tee Filter present? ❑ Yes P _No If yes, was it cleaned? ❑ Yes ❑ No
5. Obsery d condition of component pumped:
G `2-- All of this estimated
information is n-binding valid only at the time of pumping. Not responsible beyond the date above.
6. Syste m ed B -
G
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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