HomeMy WebLinkAboutSeptic Pumping Slip - 203 Boxford St - Septic Pumping Slip - 203 BOXFORD STREET 8/30/2024 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.
A. Facility Information
Important:When.
filling out forms I.- System citication:
on the computer,
use only the tab
key to Move your Address
cursor-do not
use the return 4 V,
key. (5it—YI—Town State -Z[P�Code -
2. System Owner:
-Name o a V1 V)
Address(if different from location)
City/Town State Tip Code �
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
I Component: El Cesspool(s) Pseptic Tank El Tight Tank R Grease Trap
7 Other(describe): -
4, Effluent Tee Filter presenttj�Te) [I N6- If yes, was it cleaned? F No
S. Observed condi io o component pumped:
C2,7(�o
6. System Pumped By:
Name Vehicle License Number
12
Company f
7. Location wher contents were disposed:
Signature of Hauler bate
Signature of Receiving Facility(or attach facility receipt) Date
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