HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 22 FULLER ROAD 4/29/2024 Commonwealth of Massachusetts TUN� ;e to A�dovor
City/Town of
System Pumping Record ApR292024
Form 4
DEP has provided this form for use by local Boards of Health. Other f rms may be used, but th'e nt
information must be substantially the same as that provided here. BeffSre-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 dale in
accordance with 310 CMR 15.351.
HOUSE: front back side rear leh r ght
A, Facility Information BUILDING: ront back side rear leh right
Important:When DECK: Under
filling out forms 1. System Location:
on the computei tab'
use only the lab C. 1 'A Vl •`�"
key to move your Address � � �l\
cursor.do not �U /'v�'a MA
use the return .
key. Cilyrrown Stale Zip Code
2, System Owner:
L!n 9Z)( cnSyr\
Name
nnm
Address (if different from location) .
MA
Cilyrrown Stale
Z��_�� r Zip Code
Telephone Number
B. Pumping Record r/
1. Dale of Pumping Date 2 2. Quantify Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes/ No if yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition.of component pumped:
6U0 r^^t
6. System Pumped By.-
Dave Tiney Mass F15E121 ass 1AA95E
Name Vehicle License Nu be(
Baleson Enterprises, Inc.
Company
7, ion where contents were disposed:
GLSD
Signature of Hauler Dale
Signature of Receiving Facility(or attach facility receipt) Dale
15form4.doc 11/12
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