HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 80 BOSTON STREET 7/29/2026 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 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. 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 CIVIR 15.351. ht_
HOUSE: front Cack side rear left i
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not MA C-))S-1 1-K,
use the return
key. itylfovwn State Zip Code
2. System Owner:
Name
Address(if different from location)
MA
City[Town State Zip Code
- c� 7 e�--- �'�/-P�
-telephone Number
B. Pumping Record A,
1. Date of Pumping 2. Quantity Pumped:
Gallons
1 Component: ❑ Cesspool(s) Septic Tank 7 Tight Tank 7 Grease Trap
❑ Other (describe):
4, Effluent Tee Filter present? Yes No If yes, was it cleaned? /Z"Yes M No
5, Observed condition of component pumped:
6. System PiAmped By:
_gave Mass 1AA95E� Mass 1AD31Z
Name LVehicle L�icens:eymber
Bateson Enterprises, Inc.
Company
7. on where contents were disposec:
'G on
S g_n� ul_
er Date
716n-
_§T�n_at,reof R�ceivin_g Facility-(or att-ac-h---f-a---c-il-i--t-y--r-ac-elp-t) -[5 a-te -------------------------
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