HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 543 FOREST STREET 11/10/2025 Commonwealth of Massachusetts Toleof tV0* nov
p City/Town of
_ stem Pumping Record
p No V 2025
01
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DEP has provided this form for use by local Boards of Health. Other forn, s p
information must be substantially the same as that provided here. Before using this for , c e our
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, 15
use only the tab
key to move your Address
cursor-do not MA
use the return
key. City/Town State Zip Code
P�
2. System Owner:
Name
rtren
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:
All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. Syste7elopment
ed By:
A
°Name Vehicle License Number
J&S D 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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