HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 55 SOUTH BRADFORD STREET 3/3/2026 Commonwealth of Massachusetts
City/ own of
T
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health, Other formi maybe used, but the
information must be substantially the same as that provided here. Before using this fbrm, check with your
Iocai 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 i 5.351,,
A. Facility Information of
Important:When 1dover
filling out forms System Location:
on the computer, j
use only the tab JUN 2 6 2026
key to move your Address
cu=r-do not—
use the return f''�ex
key, City/Town State �alth,
2, System Owner
V, C
Name
Address(if different from location)
Z-ity-rrown state Zip Code
Telephone Number
B w Pumping Record
I, Date of Pumping sate 2, Quantity Pumped: Gallons
3. Component: cesspool(s) Septic Tank 7 Tight Tank 7 Grease Trap
F7 Other(describe):
4. Effluent Tee Filter present? 7 Yes El No If Yes, was It cleaned? Yes ❑ No
5. Observed condition Of component pumped:
6, System Pumped By:
I'll; 10
Name Vehicle License Number
Wayne's Drains, Inc.
Company
7 Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Pacllit (or attach facility receipt) Date