HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 769 FOREST STREET 12/12/2025 Commonwealth of Massachusetts
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. 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 -,he pumping date in
accordance with 310 C M R 15.351
HOUSE: front ack )side rear leftC
A. Facility Information BUILDING� front b�ck side rear left rig�t'
Important;When OFCK: under
filling out forms 1. Systern Location:
on the compulef, -4
use only the (ab
key to move your
cursor- do not MA
use (he fetufn
key CHyffown State Zip Code
2. System Ow per.
Narne
fetWR
------------------ ----------------
Address If different front ocWlon)
MA
Clty/Town Stale Zlp Code
-Q
Telephone Number
B, Purnping Record
1, Date of Pumpinggate 2. Quantity Pumped: Gallo.ns
1 Component: ❑ Cesspool(s) 0-,8-elptic Tank ❑ Tight Tank ❑ Grease Trap
L] Other (describe): -------- ------—---------
4, Effluent Tee Filter present? E:1 Yes aeKo If yes, was it cleaned? E] Yes E] No
5. Observed condition of component pumped.
6. S�4't e rn /,jrnped By
1lney Mass I AA9 EE Mass IAD31Z
NarYie Vehicle License umber
�'Baleson EMerl)rlsps, Inc
C crn o a n y
7 ocNi r) wh,e,'erite is were disposed:
-5D
----------- ------------------- ........
Signature of Hauler -Date----
----------
Signature of Receiving'Facility (or attach facility receipt) (late
15lorni4.doc' 11112 Systern Pumping Record Page 1 of 1