HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 324 BRADFORD STREET 11/21/2025 Commonwealth of Massachusetts
)c, A "i? c"'�e[Vo 4ndWer
City/Town of K_
System Pumping Record OEC �025
Form 4
DEP has provided this form for use by local Boards of Health. Other 411way b3Ased,,,,but the
information must be substantially the same as that provided here. Before using tWis tn?ftth your
local Board of Health to determine the form they use. The System Pumping Record must .be s; itted 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 3
key to move your Address
cursor-do not MA
use the return
key. City/Town State Zip Code
2. System Owner:
Dbma AN(—
Name
reuse
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record 1 5
1. Date of Pumping 2. Quantity Pumped:
ot Gallons
3. Component: ❑ Cesspool(s) 711Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? 7 Yes 51"No If yes, was it cleaned? 7 Yes No
5. Observed conditio 7 om Cponent pumned-
All of this estimated
information is no only at the time 91SuMRIDg. Not responsible beyond the date above.
6. System Pumped By:
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.W_Sf.—Sradford MA01835
See above
Signature of auler --Date-
See above
-Signature of Receiving Facility(or attach facility receipt) Date ----------
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