HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 410 FOSTER STREET 10/10/2025 Commonwealth of Massachusetts
x City/Town of k L)Q r
System Pumping record
❑W Form 4
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 focal 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 Cade
2. System Owner:
i
Name
rerean
Address(if different from location)
__ _ .......
City/Town State Zip Cade
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. System P ped By: -
❑ �
Name Vehicle License Number
J&S Devi I pment 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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