HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 FOSTER STREET 4/29/2024 Commonwealth of Massa'ehusetts
City/Town of QpR 2 9 2p24
System Pumping Record
Form 4 .,, ltt
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.
HOUSE: front bac side ear left right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Lolion.
on the compulel, ,/ r
use only the lab
key to move your Address
cursor-do not �/ . �an� MA
use the return
key. ityrrown Stale Zip Code
2. System Owner:
r.a i �
Name
Mun
Address (if different from location).
MA
Cilyrrown Stale
Zip Code
tilt 3-!FY6Z 5_� S
Telephone Number
B. Pumping Record
1. Dale of Pumping oate(L 2. Quantity 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:
i
6. System Pumped By:
Dave Tiney Mass F5821 Mass 1AA95
i Name Vehicle license Nu ber
Baleson Enterprises, Inc.
Company
7. aljon where contents were disposed:
GLs.
Signature of Hauler Dale
Signature of Receiving Facility(or allach facility receipt) Dale
t5form4.doc• 11112
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