HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 215 RALEIGH TAVERN LANE 11/17/2025 Commonwealth of Massachusetts 'rov"'i"y "J)
-L A n do Ver
City o f/Twn o L
System Pumping Record DEC
Form 4 2025
DEP has provided this form for use by local Boards of Health. Other ut the
information must be substantially the same as that provided here. Before using thas-Vow, mentith 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 compjter,
use only the tab o"
key to move your Address
cursor-do not
use the return MA
key. City/Town State Zip Code
2. System Owner:
Name
raven
Address(if different from location)
Cityi7own -State - Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date Quantity Pumped: Gallons
3. Component: F7 Cesspool(s) Septic Tank F7 Tight Tank El Grease Trap
1*7 Other(describe):
4. Effluent Tee Filter present? F7 Yes No If yes, was it cleaned? 7 Yes 7 No
5. Observed condition of compcne pumped:
All of this estimated
informationumpang. responsible beyond the date above.
6. System P mpe Name -1�e-hicie License Number
J&S Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewarts Global Environmental, LLC
20 So. Mill St., Bradford, MA 01835
See above
-Signature Of Hauler - Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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