HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 23 SULLIVAN STREET 10/21/2025 �L\ Commonwealth of Massachusetts
City/Town of bg.� jan&oei
System Pumping Record
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 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 a5 1-05W t I M n lq�4—
key to move your Address
cursor-do not MA
use the return City/Town State Zip Code
key.
2. System Owner:
Name V
ramri
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Quantity Pumped: ry
oate la-lions
3. Component: F7 Cesspool(s) a4l;tic Tank F-7 Tight Tank E Grease Trap
F7 Other(describe):
4. Effluent Tee Filter present? F7 Yes /No If yes, was it cleaned? 7 Yes a/4
5. Observed c ndition of component pumped:
&0 1-1- All of this estimated
information isnon-binding,_valid only at the time of um in . Not res onsible beyond the date above.
6. System Pumped By:
Ixu"k
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 M.
20 So. Mill St., Bradford, MA 01835
See dBove
Signature of
Date
See above
Signature 0—fReceiving Facility(or—attach facility receipt) Date
t5form4.doc-11/12
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