HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 730 BOXFORD STREET 9/9/2025 ,L**\ Commonwealth of Massachusetts
City/Town of ARC(,0 ver w SEP 2 22025
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, T-Own Of. icifth Andovef-
A. Facility Information
Important:When
filling out forms 1. System Location: SEP 2 2 2025
on the computer,
use only the tab
key to move your Address
cursor-do not 11AL-EM kdover A10- Health
use the return CKyrTown state Zip Ca a
key.
2. System Owner:
fsra
Name
Address(if different from location)
CityfTown state Zip Code
z
TelepliffieMumber
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: El Cesspool(s) Ef-'Septic Tank F1 Tight Tank n Grease Trap
n Other(describe):
4, Effluent Tee Filter present? n Yes No If yes,was it cleaned? El Yes F] No
5. Observed conditign of component pumped:
6. System Pumped By: W6
rd—
Name r Vehicle License Number
Company I
7. Location where contents were disposed:
-Signatu, 0 uler Date
Facility(or attach facility receipt) Date
Signature of Re '?gac-1fity(o'
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