HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 206 BOXFORD STREET 12/22/2025 4 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 [his form, check with your
local Board of Health to determine the form they use. The System Purtnping 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.
HOUSE: front ac side rear lef-t rig,
A. Facility information BUILDING: Front back side rear left right
Important: When DECK: under
fling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not / >
use the return —n ---.-_—_._ __.._. __.. ._.__._ - __.. M
key. ity/TOwn
r 2. System Owner,
( ) �\ Name
return ! �v
Address(if different from location) -
MA_
_Gip Code
Telephone Number
B. Pumping Record
1. Date of Pumping '.�� _...._
p 9 oats `---- ___- 2 Quantity Pumped,
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): --- --._------- -—�— -- --_ --—
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component urnped
6, System Ptamped By:
Dave Tlney -__-------------�__ _. - .__. __.- Mass 1 AA99 ` Mass 1 AD31Z
Narne Vehicle L.(cc n Tiber
Bateson Enterprises, Inc,
Company -
7, Location where contents were disposed:
LS -
mfgn �eauler Date — —
Signature of Receiving Facility (or attach facility receipt) Date - -- -
t5form4,doc• 11112
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