HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 234 HAY MEADOW ROAD 10/30/2025 �L\ Commonwealth of Massachusetts
City/Town of u,
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 oomp;,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
raacn
Address(if different from location)
City/Town state Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Quantity Pumped:
Date Gallons
3. Component: F7 Cesspool(s) septic Tank F71 Tight Tank F7 Grease Trap
71 Other(describe):
4. Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? 7 Yes 7 No
5. Observed condition of c pone pumped:
All of this estimated
information is non-bindi at the time of pumping. Not responsible beyond the date above.
6. System P g p!Ly
Name Vehicle License NumbW
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., E3radford, MA 01835
See above
Signature of Hauler Date
See above
T19—na—W—re of Receiving Facilty(or—attach facility receipt) Date
t5form4.doc-11/12
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