HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1794 SALEM STREET 11/25/2025 Commonwealth of Mass chin tts
City�Town caf - � �,d
GSystem Pumping Record N011hAnd0ver
, Form 4 7
M DEC 2025
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., fore using this form, check with your
local Board of Health to determine the form they use. The System] �iar'i"0i g F,� O omitted to
the local Board of Health or other approving authority within 14 days from the pu�hpl
accordance with 313 CMFt 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the comi;,iter,
use only the tab 14
key to move your Address —
cursor-do not
use the return MA
own Ci !1 -
key. t State Zip Code
c�
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Cade
Telephone Number
B. Pumping Record
1. Date of Pumping t
p g D e — 2. Quantity Pumped: Irons
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes JJXNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
(11�4E, 4111 of this estimated
information is non-bindin , vaiid onl at the time of um i i. Notre,,s onsible beyond the date above.
6. Sys P ped By: ,
Name Vehlcie License Number
AS 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 01 835
See above
Signature of Hauler Date
See
Signature of Receiving Facility(or attach facility receipt) Date shave
t8form4.doc• 11/12
System Pumping Record•Page 1 of 1