HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 379 BOXFORD STREET 11/5/2025 Commonwealth of Massachusetts T""r ( f M)rth Aridolleir
City/Town of Avxkver- UAR -2 2026
System Pumping Record
Form 4 " °
��'2 rtrn en t
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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, 1'1� 111� --V'—d t��-
use only the tab -------------
key to move your Address
cursor-do not N A i-�c�o,�
use the return
key. City/Town State Zip Code
2. System Owner:
I U
Name
............ ------------------------------------ ................ ..............
Address(if different from location)
City/Town state Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date Quantity Pumped: ..Gallo-n.s.-I-1-1------------------
3. Component: R Cesspool(s) (Septic Tank R Tight Tank ❑ Grease Trap
F-1 Other(describe): ........I..-.".",..",,-,..�-.,..-�...-��-I---------------
4. Effluent Tee Filter present? [] Yes &?(No If yes, was it cleaned? F1 Yes R No
5. Observed condition of component pumped:
........... C)t-D-ct...........................................---.................................................------------------------- -------------------
6. System Pumped By:
i6rd -----------
..... ................
Name Yehicle License Number
Company
7. Location where contents were disposed:
igR' ure of H ler Date
Signature 6T'-�e�ceiving Facility(or attach facility receipt) Date
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