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HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 734 Boxford Street 6/16/2025 TQ�yn �f�o�h Commonwealth of Massach(,asetts �n�aVer City/Town of __.. _ JUN x s a 6 2025 -- System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms rnay be (ised, but the information roust be substontially the sar-ne as that provided here. Before t.ising Ihis form, check will) yor.lr local Board of Health to determine the forrn they i-ise. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the purnping date in accordance with 310 CMR 15,351 ------ HOUSE. front back si e rear le nph A. Facility Information — BUILDING: front back side rear left right Important:Whon DECK: under filling out forms 1, System Lo tion. on the cornpuler, use only the lab — key to move your Ad i(©9p� cursor•do nol MA C f use the return ----------- _—_-- _ —L key, -------- Cily(Town Slate -- --- Zip Code 2. Sys rn Owner: S Name ------------------ ------_ Address (if different from location) MA ClfyfTown State Zip Code Telephore umber B. Pumping Record 1. Date of Pumping L—L"> ---- 2. quantity Pumped. ----- Date Gallons 3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap L� Other (describe): -- ---._.-.._.__ ._.___..__-.-----._.—._.__---------__.__—_.— 4. 'Effluent Tee Filter present? ❑ Yes j No If yes, was it cleaned? El Yes ❑ No 5. Observed /c)oonn'dition f component pun'iped: 6. System Pumped By: Qave Tlne Mass 'IAA95E Mass 1AD3'1 ---- y_ .---- ..._—.- --- . --- — - -- — - Name Vehicle License Nu _ _ gnfesnn Enlerpris�s, Inc. Company ------ —----- 7, ation where contents were disposed: G�'S Signature of Hauler Dale Signature of Recelving Facility (or aCiaet7 facility receipt} Date l3form4.doc, i1112 SyStCMPumping F2eroid Page t of i