HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1278 OSGOOD STREET 12/3/2025 Town of Commonwealth of of over
And Massachusetts
City/Town of
System Pumping Record DEC - 8 2025
Form 4 Health Department
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 1. System Location:
on the computer,
use only the tab 'k
key to move your Address 4"
cursor-do not
use the return
key. Cityl I-own
Male
2. System Owner
'Name
Address(if different from location)
City/Town
State ————Zip Code----
fe—le—ph"o�Number�����
• Pumping—--Record--
1. Date Of Pumping — ' L
.P. 2. Quantity Pumped: _Q
3. Component: 0 CeSSPOOI(S) Septic Tank 0 Tight Tank G-11�n--s
0 Other(describe): El Grease Trap
4. Effluent Tee Filter present? 0 Yes 0 No If yes, was it cleaned? 0 Yes n No
5. Observed condition Of component Pumped:
6. System Pumped By:
Al C� 1('-�
Name f 6/5
V,
venicie License Number
company
7. Location where contents were disposed:
LIS
Sign Mof Hauler
Signature of Receiving Facility(or attach facility receipt)
Date
t6fbrm4.doc-11/12
System Pumping Record
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