HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 76 BOXFORD STREET 7/13/2026 IUWW11 Ul IVUI U i t11lUUVGi
Commonwealth of Massachusetts JUL 1 2026
City/Town of
stem Pumping Record
Y 1-lealth Department
Farm 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. Tho 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.
--------.______ —__---------.. HOUSE: front6"'
ck side rear le rig171
A. Facility Information BUILDING: front back side rear left right
important:When DECK: under
tilling out forms 1. SysterT Lo on:
on the computer, 4flG•+�w
use only the tab _...� . _
key to move your Address
cursor-do not MA
use the return
key, City/town State Zip Code
2. Sys e t�Owner:
, .
Nance _
lEttYl1 / \)
Address (if different from location)
MA
City/1'awr7 _ Sta Lip Code..
Telephone Number w
B. Pumping Record
1. Date of Pumping _. _ _------ 3. Quantity Pumped.
Date y p ens
3. Component: ❑ Cesspool(s) ❑ ptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition o c nponent pumped:
& Syste Pumped By:
veTlney Mass 1AA95E Ma 1AD31L
amen Vehicle License plumber
Bateson Enterprises, Inc.
Cornpdny
7. ovation 0�lereGLSD o ents were disposed.
6rgnature of Hauler Cate
Si nature of Receiving Facility receipt) _.._...._. ....__.____. _----___._--
g g y(or attach facility recui t Date
t5form4.doc• 11112 System Purnping Record •Page 1 of 1