HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 41 CHERISE CIRCLE 11/12/2025 @IJVYII L), nui tri /Anciover
<L\ Commonwealth of Massachusetts
City/Town of 12p�v� &wtr DEC - 12025
System Pumping Record
Form 4 L� Pal rb'k'",ont
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 com,,jter,
use only the tab ,-�a Q. ------
key to move your Address
cursor-do not MA
use the return
key. City/Town State Zip Code
2. System Owner:
------------
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ---
t 2. Quantity Pumped:
Date Gallons
3. Component: 7 Cesspool(s) [Septic Tank 7 Tight Tank 7 Grease Trap
7 Other(describe):
4. Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? 7 Yes 7 No
5. Observed condition of component pumped:
� 00j All of this estimated
information the time�Umpi Not responsible beyond the date above.
6. System Pumped By:
/V1 0.LS_0m__
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
c c
Y, X 0 11 See above
Signature of Hauler Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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