HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 50 BOXFORD STREET 5/21/2026 Commonwealth of Massachusetts r00 Of Alorth
4
City/Town of 17doVer
System Pumping Record
JOIN
Form 4 20a
DEP has provided this form for use by local Boards of Health. Otheqr9AUhat used, but the
information must be substantially the same as that provided here. Before using t ck ut with your
local Board of Health to determine the form they use.The System Pumping Recordtmuismmitted 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 ---------- --------- --------- -------------
key to move your Address
cursor-do not
use the return
. ...................
..........
key. City/Town State Zip Code
Q2. System Owner,
------
ea me"'-
---------- -----------------------------------------
Address(if different from location)
-dioii ................... ........................................ .............--1.---.---...-.--------------
)to .............wn State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping D-a I t I e---l- 2. Quantity Pumped: -G-allons-.......... .......
3. Component: ❑ Cesspool(s) VSeptic Tank r-1 Tight Tank R Grease Trap
nOther(describe): ..................................... -----------....................................
4. Effluent Tee Filter present? Ej Yes 19,No If yes,was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
........................
6. System Pumped By:
---e�tm ---------------------------------- ------- ------------------- ...........................
Name Vehicle License Number
_(..........
Company
7. Location where contents were disposed:
Q) ................ ------------ ...---------------. ............................. .................... -------......................
. . ........ ----------
Signat6re of Hauler Date
Signature--of,Receiving- Facility(or attach--facility receipt)--- - Date
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