HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 537 BOXFORD STREET 7/21/2023 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
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 CMR 15.351.
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A. Facility InformWRigt
LeftRig nt of house, Left/Right rear of house, Left/Right side of house, Under C
Important:When Left e of buildin Left/Ri ht front of building, Left/Right rear of building,
filling out forms 1. System Location: g g
on the computer, ( S
use only the tab K
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Y
key to move your Ad ress
cursor-do not MA ilk HC
use the return CitylTown State Zip Code
key.
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2. System Owner:
Name
iemm
Address(if different from location)
MA
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes 4 No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
i
' 6. System Pumped By:
Dave Tiney Mas ;5 MIA 6+1%5?
Name Vehicle tic umber
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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