HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 135 JOHNNY CAKE STREET 12/31/2025 Commonwealth of Massachusetts To of No r
City/Town of
JAN
System Pumping Record
Form 4 Health Department
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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not MA
use the return
key. City/Town state Zip Code
2. System Owner:
Rims I
learn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2, Quantity Pumped: 2.600
Date -Gaiions
3. Component: 7 Cesspool(s) _tz 7 17 Septic Tank Tight Tank ❑ Grease Trap
F7 Other(describe):
4. Effluent Tee Filter present? F7 Yes No If yes, was it cleaned? F7 Yes 7 No
5. Observed condition omponent pupqd: L c.I ,
4A All of this estimated
information is noning- va
lid.—oAlyatthdimect t responsible beyond the date above.
6. SystFmLP-_umped By:
e t��
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
0,of Q�
Date
Signature of Receiving Facility(or attach facility receipt) See above
Date
t5form4.doc- 11/12
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