HomeMy WebLinkAboutSeptic Tank - Soil Testing Results - 20 COLONIAL AVENUE 10/24/2023 ,CN- Commonwealth of Massachusetts
City/Town of ��oti3
a
System Pumping RecordL��
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 CMR 15.351.
A. Facility Info,,ym tion
l Left ight front of house, Left/Right rear of house, Left/Right side of house, Under f
Important:When
filling out forms 1. S stem Location: Le Right side of building, Left/Right front of building, Left/Right rear of building,
on the computer, ` �ij e
use only the tab `� —
key to move your dress
cursor-do not /v !A" MA V `�
use the return City/Town State Zip Code
key.
2. Slystem O ner:
Name
Address(if different from location)
MA
Cityrrown — -- _ ---- State (Z3 _ C/�'Z- 77�
Telephone Number
B. Pumping Record
2. QuantityPumped: �--
1. Date of Pumping Date Gallons
3. Component: ❑ Cesspool(sASeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): -- --- -
4. Effluent Tee Filter present? ❑ Ye If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tines
Mass F582
Name Vehicle Lice se umber
Bateson Enterprises, Inc.
Company
7. cation wrier contents were disposed:
GLSD
Signature of er Date
Signature of Receiving Facility(or attach facility receipt) Date
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