HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 657 FOREST STREET 7/24/2026 /~[lmm[][]wea|th of Massachusetts
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System Pumping Record
Form 4
DEp has provided this form for use by local Boards of Health. Other forms may he used. but the
information must be substantially the same as that provided here. Before using this form, check with your
\Voo| 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
ear left ight
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A. FaC'i^fw Information BUILDING: front back side rear left right
Important:
under
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filling out forms 1. System Lo d
on the computer,
use only the tab
key u`move your Address
cursor'uo no,
use the return '
key� City/TownState _- Code
2. System Owner:
CalAddress(if different from location)
MA
City(Town Stat Zip Code
?� C*
B. Pumping Record
1, Date OfPumping -bate2� Quantity Pumpod�
Gallons
[� �� [� [�
3� Component �� Cesspool(s) .opdo Tank �� Tight Tank �� Grease Trap
Other (describe):
4, Effluent Tee Filterpresent') Y Yes ZNo If yes, was it cleaned Yes E] No
� —
5. Observed condition of &onent pump d
S. S em P ped By: qf
py,
'ame Vehicle License Nu
Batei6n Enterprises, Inc.
Zompany
7.
�ation where conten s Vwere disposed:
Signature of Hauler Date
t5fonn4.doo' 11112 System Pumping Record `Pugo 1 of