HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 203 MILL ROAD 4/17/2024 Commonwealth of Massa`chus,etts
City/Town of
a System Pumping Record pR17 ti��4
P
Form 4 t
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the` l
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.
HOUSE: front back side rea left ight
A. Facility Information BUILDING: ront back side rear left right
Important;When
DECK: under
tilling out forms 1. System Location:
on the '
ter
use onlyly the the t labb
key to move your Address
cursor•do not _ MA
use the return
key. Cily/Town Stale Zip Code
r� 2. System Owner:
1Qt��
Name
nrtrn
Address (if different from location) .
MA
Cilyrrown Stale Zip Code
Ct_�'&_'�S 'G�ZcS
Telephone Number
B. Pumping Record
1. Dale of PumpinAg A!f
p g 2. Quantity Pumped:
Dale
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes �] No It yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition.of component pumped:
6. System Pumped By:
Dave Tiney Mass F5821 �195E
Name Vehicle License Num r
Baleson Enterprises, Inc.
Company
7. lion where contents were disposed:
GLSD
Signature of Hauler Dale
Signature of Receiving Facility(o(attach facility receipt) Dale
l5form4.doc- 11/12
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