HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 INNIS STREET 10/28/2025 1L\ Commonwealth of Massachusetts
CityfTown of )LETc�
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 comp:,ter,
use only the tab
key to move your Address
cursor-do not MA
use the return City/Town State Zip Code
key.
2. System Owner:
Name
Address(if different from location)
City/Town -State Zip Code
Telephone Number
B. Pumping Record lc� J000--
1. Date of Pumping Date' - I - -- 2. Quantity Pumped: Gallons
3. Component: F7 Cesspool(s) 7 Septic Tank F7 Tight Tank ❑ Grease Trap
7 Other(describe):
4. Effluent Tee Filter present? F7 Yes &?No If yes, was it cleaned? F1 Yes 7 No
5. Observed condition of component pumped:
Q000 All of this estimated
information is non-bindinqAlid only at the time of pum in . Not responsible beyond the date above.
6. Sys mped By:
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 0 1835
See above
Signature of Hau-M—r Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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