HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 191 HAY MEADOW ROAD 10/30/2025 Commonwealth of Massachusetts
City/Town of _L-LL 4) S"
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 I, System Location:
on the computer,
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
1. Date of Pumping 2. Quantity Pumped:
pate Gallons
D
- -t
3. Component: ❑ Cesspool(s) Septic Tank F7 Tight Tank F7 Grease Trap
7 Other(describe): 11
4. Effluent Tee Filter present? F7 Yes No if yes, was it cleaned? 7 Yes No
5. Observe 4 condition of component pumped:
r
All of this estimated
information is non-binding, valid only at the time of pumping. Not res onsibie beand the date above.
6. System Pumped 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 01835 42�5
See above
Signature of Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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