HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 2109 TURNPIKE STREET 11/10/2025 ,vvi 111/incover
Commonwealth of Massachusetts NOV 10 2025
City/Town of
System Pumping Record
Form 4 �,`)Parf'Ment
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 a I D q ll(,T r-N o,
key to move your Address
cursor-do not MA
use the return City/Town State Zip Code
key.
tlll_� 2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record _S-w
1. Date of Pumping ua ntity Pumped: Gallo
ons
ns
1 Component: F7 Cesspool(s) S�eptic Tank 7 Tight Tank ❑ Grease Trap
7 Other(describe):
4. Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? 7 Yes 7 No
5. Observed Condit' n of cc ponent pumped:
dy V All of this estimated
information is non-binding, valid the time of pumping. Not responsible beyond the date above.
6. System C�
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
Signatureof Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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