HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 203 BOXFORD STREET 9/16/2025 Commonwealth of Massachusetts ` 'r v, dover
(,@a City/Town of
System Pumping Record OCT 6 2025
Farm 4
DEP has provided this farm for use by local Boards of Health. 4n� �u�tt 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 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return
key. City/Town State
Zip Cade
f�
2. System Owner;
—41
Address(if different from location) --- _•—.-...._____ _...__...._._.__._
City/Town
State Zip Code
Telephone Number -�-. ..__.....__.._,.........__.._....
B. Pumping Record
1. Date of Pumping Gate ---- 2. Quantity Pumped: ! _.__.
Gallons
3. Component: Cesspoo(=O'Septic arn ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter pres t? Yes ❑ No-- If yes, was it cleaned n Ye ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
ame Vehicle License Number
P Y
7. Location where contents were disposed;
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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