HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1493 FOREST STREET EXT 10/20/2025 Commonwealth of Massachusetts
ffi ' 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, eefore, 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 'he pumping date in
accordance with 310 CMR 15351.
HOUSE: front back side rear left right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms I, System Location:
on lhe computer,
Use only the(ab
key to MOVe YOW Address
--
cursor -do not No'r
use the return K--
MA
key. Cllyfron Stale
Zip Code
2, System Owner
"4--- r, i
Name
------------
Address (it different from location)
MA
C{ly� own Slate Zip Code
TA- .n
Telephone Number
B. Purnping Record
Wo
1. Date of Pi-ji-Tiping Date 2. Quantity Pumped'. Gallons
3. Component'. ❑ Cesspool(s) [VIISeptic Tank Tight Tank Grease Trap
Other (describe): -----------
4. Effluent Tee Filter present? Yes o If yes, was it cleaned?? E] Yes ❑ No
5, Observed condition of component pumped:
----------
6, System Purnped By:
Dave They Mass IAA95E Mass 1AD31Z
Name Vehicle License Number
39fesor) Enterprises, Inc
Crrmpany
7 Location where contents were disposed
G L5 D
Signature of a'UI GaleSignature of --
----------------
Receiving facility (or attach facility receipt) Date
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