HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 105 CARLTON LANE 4/29/2024 Commonwealth of Massachusetts T014n0jNo�hAn ova
City/Town of
System Pumping Record APR292024
Form 4 t
DEP has provided this form for use by local Boards of Health. Other forms�-tr�y be use f;btJrt�e
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 dale in
accordance with 310 CMR 15.351.
HOUSE: front back side rear (0 right
A. Facility Information BUILDING: front back side rear leh right
Important;When DECK: under
tilling out forms 1. System Location:
on the computer,use only the lab rGs ,
key to move your Ad ress
cursor•do not �-4��`�dLJ� MA
use the return
key. Cilyrrown Stale Zip Code
2. System wner:
- '
r �
Name
nnm
Address (if different from location) .
MA
Cilyrrown State Zip Code
Telephone Numbef
B. Pumping Record
1. Date of Pum to u�is Z P
p g Date 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 condittion.of component pumped:
6. System Pumped By:
Dave Tiney Mass F5821 Mass 1AA95E
Name Vehicle license N ber
Baleson Enterprises, Inc.
Company
7• Location where contents were disposed:
rGLS�
Signature of Hauler Dale
Signalwe of Receiving Facility(or attach facility receipt) Dale
l5foirnkdoc, 11112
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