HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 153 HAY MEADOW ROAD 4/20/2026 � Commonwealth of Massachusetts TO" cf 1�10rttl`WOVer
City/Town of k-)c> N,8N,,Q/ MAY -6 2026
System Pumping Record
Form 4
fl [)e
DEP has provided this form for use by local Boards of Health. Other forms may be us6d?VAVQnt
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 CMR 15.351.
A. Facility Information
Important When
filling out forms System Location:
on the computer,
use only the tab L55 1—\4CA Sj M alLks�
key to move your Address
cursor-do not MA
use the return
key. City/Town state Zip Code
2. System Owner:
4 P 4
Name
Address(ff different from location)
city
fTown State Zip Code
Telephone Number
B. Pumping Record
-1. �t 1 2. Quantity Pumped:
4 Date of Pumping oat Gallons
I Component: 7 Cesspool(s) % Septic Tank I Tight Tank 17 Grease Trap
F7 Other(describe):
4. Effluent Tee Filter present? �� Yes 1-1 No if Yes, was it cleaned? I Yes 7 No
S. Observed cand-lon of component pumped:
AH Of'this estimated
information is non-bindin 'the time of pulilr . Not responsible be cnd the date above.
S. System P mped By:
Name Vehicie 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. i for MA 01835
See above
signaiti*of Hauler Date
Signature cf RecalvT See above
ng Facility(or attacl-,facility receipt) Date
t5fOM14-doc-11/12
System Pumping Record•Page 1 of 1