HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 35 BOXFORD STREET 10/24/2025 �L\ Commonwealth of Massachusetts
City/Town of kx.�,
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, t�—
use only the tab
key to move your Address
cursor-do not MA
use the return City/Town State Zip Code
key.
41--�
2. System Owner:
Name
Address(if different fromlocation)
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 F71 Tight Tank ❑ Grease Trap
F7 Other(describe):
-
4. Effluent Tee Filter present? F7 Yes X NaL If yes, was it cleaned? 7 Yes 7 No
5. Observed cond' ion of component pumped:
C 1 All of this estimated
information is non- le beyond the date above._
6. Sys Pumped B
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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