HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 267 BOXFORD STREET 1/9/2026 Commonwealth of Massachusetts
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System Pumping Record
lug 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 the Pumping date in
accordance with 310 CMIR 15-351.
A. Facility information
Important:When
filling out forms 1. System Location: 1U9W1j1@dAQ LjJ19()H
on the computer,
use only the tab Q(611
key to move your Address .
cursor-do not
use the return
key. Qtyi I own
state
Z* Code
2. System Owner: XWC, V� po 10 UM0j
Name
rain
Address(it different from location)
Cltyi I own State� zip—C—o—de
TeWp�hone Number
B. Pumping Record
I. Date of Pumping rl 1A,,
Date 2. Quantity Pumped:
Gallons '"
3. Component: 0 Cesspool(s) Septic Tank n Tight Tank D Grease Trap
[3 Other(describe):
4. Effluent Tee Filter present? n Yes 0 No If yes, was it cleaned? ❑ Yes n Na
5. Observed condition Of component Pumped:
6. Sys em Pumped By:
N
vehicle License Number
Company
7. Location where contents were disposed:
Sign f Hauler
Signature of Receiving Facility(o�a—lla(i��ciiity receipt) Date
t5fbrm4.doc-11/12
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