HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 86 FOREST STREET 4/28/2026 T oWn 'of lVorth AndWer
L\ Commonwealth of Massachusetts
City/Town of
SUN 2026
System Pumping Record
Form 4
"ea"' L)e
DEP has provided this form for use by local Boards of Health. Other forms may be usPd,qftoent
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 's
key to move your Address
cursor-do not
use the return
-----------
key. City/Town State Zip Code
2. System Owner:
VQ
................
Name
..................... --------------
Address(if different from location)
..........................___________..—---------------------------------------- ...............
City/Town State Zip Code
R J3
-------
Telephone Number
B. Pumping Record 10bo
1. Date of Pumping Date .................. 2. Quantity Pumped: -Gallons-----------
3. Component: M Cesspool(s) M//Septic Tank Fj Tight Tank M Grease Trap
F] Other(describe): ------------
4. Effluent Tee Filter present? R Yes No If yes,was it cleaned? R Yes F] No
5. Observed condition of component pumped:
6. System Pumped By:
LIV a
Name Vehicle License Number
'7
Compan J
7. Location where contents were disposed:
.............------- ................................ .........
14 -Lzsl /.Z� .............
----------- ------I--------------------------
Signature of Hauler Date
attach facility receipt) Date
--§,�g—nWt6-re---o--f'-R'ec—eivi-n-g--F---ac-il-i-t"-y-—(or
t5form4.doc-11/12 System Pumping Record-Page 1 of 1