HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1430 GREAT POND ROAD 11/12/2025 T Own of&'Orth 4ndOver
Commonwealth of Massachusetts
DEC
City/Town of o,,
2025
System Pumping Record
Form 4 D
e,
DEP has provided this form for use by local Boards of Health. Other forms may be used, bI.rPpint
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
of*-� 2. System Owner:
�-& & -------------
Name
............... -----------------
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
2. Quantity Pumped:
1. Date of Pumping eons
Dail
3. Component: 7 Cesspool(s) �'Septic Tank 7 Tight Tank 7 Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes P No If yes, was it cleaned? 7 Yes 7 No
5. Observed condition of component Aped:
(f-7010 7 All of this estimated
information is non-binding, valid only tt e.tlme of pum i9R. Not Ee§pqr1sitle peyqnd the date above.
6. S St P y, d
-Aame Vehicle License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were dig posed:
Stewart's G Enviro Pig1-L
201S Bra 83
See above
Signature o Hauler Date
See above
7Signature of—Receiving—Facility—(or-"attach facility receipt) Date
t5form4.doc- 11112 System Pumping Record-Page 1 of 1