HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 40 OXBOW CIRCLE 10/31/2025 Commonwealth of Massachusetts
lCity/Town of
System Pumping Recd ug or 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 compc.ter,
use only the tab
key to move your Address
cursor-do not MA
use the return City/Town State Zip Code
key.
2. S stemOwner:
tab
Y-ci,Ae�
Name
retten
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date, Gallons
3. Component: F7 Cesspool(s) `Septic Tank F7 Tight Tank F7 Grease Trap
F7 Other(describe): I
4. Effluent Tee Filter present? F7 Yes 2/No If yes, was it cleaned? 7 Yes Na
5. Observed condition of component pumped: All of this estimated
information is non-binding, valid only at the time of pumping, Not responsible be and the date above.
6. Wtem Pumped By:
C4-0 Y,
Name Vehicle License Number
AS Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewarrs Global nvironmental, LLO
20 $q. Mi radford, MA 0 1835
See above
$�gilgtUre of Date I C) 13
See above
'Signature of Receiving Facility�(or attach facjjty-receipt) Date
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