HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 40-46 BEECHWOOD DRIVE 6/5/2026 Commonwealth of Massachusetts '0W' Of 1VO*And
OVer
City/Town of
System Pumping Record JUN 14 2026
Form 4
DEP has Provided this form for use by local Boards of Health Health Depart
. Other forms may be uTseg'Qst the
information must be substantially the same as that Provided here. Before using this form, check wi
local Board of Health to determine the form they use. The System Pumping Record must be submitted t
th your
o
the local Board of Health or other approving authority within 14 days from the Pumping date in
accordance with 310 CMR 15.351.
F—aci-1 --
11y 1nfq—rma1ion---------------_
Important:When
filling out forms I. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not
C'
use the return
key. City/Town
Zip Cade
2. System Owner state
Name
Address(if different from location)
City/Town�����.. ------
State Zip Code
PNu--r ------
u—Mp-1n—qR—ec—ord------—Telephone Number
1. Date OfPumpingtaste 2-�1 -- 2. Quantity Pumped: ✓ 30 6
3. Component: 0 Cesspool(s)
0 Other(describe): q Septic Tank El Tight Tank El Grease Trap
4. Effluent Tee Filter present? El Yes El No
If yes, was it cleaned? El Yes El No
5. Observed condition Of component Pumped:
6. System Pumped By:
Vehicle[-UDcZCRumber
Company
7. Locatif where contents were disposed:
L
Sign csf Hauler Date
Signature of Receiving
facility�receipt) I bate--------------------------------------
t5fDrm4.doc-11/12
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