HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 96 FARNUM STREET 8/3/2026 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 m�
accordance with 310 CMR 15.351.
HOUSE: fronte)ide rear le rightcility Information BUfLDING: front side rear left right
Important:When DECK: under
filling out forms 1, Sys r L tlon:
on the computer,
use only the tab .
key to move your Address
cursor-do not MA
usethe return _ .__.._..._ _ _--- -_ _ _._..... _._.____.__ _ ---------_______._____...____.
City/Town State Zip Code
Key.
2, Sy t rn Owner:
Name
Address(if different from location)
MA
Gity/Town St e Zip Cade
Tei p one umber
__..._.......
B. Pumping Record
1. Date of Pumping gate 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe); _....__...._.____._----______-____-_.._..____...__._______..._..___.
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component roped:
6. rel-ine
mped By:
_ Mass 1AA95E M ss 1AD31Z
Vehicle License Numberterprises, Inc.
7. ocatiE
e cant e disposed:
G LS D __ .__.
fignatu . er —_. _ _.____..__._...__ _Date _____._.._____�
Signature of Receiving Facility(or attach facility receipt) Date
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