HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1080 TURNPIKE STREET 5/6/2024 Commonwealth of Massa`chusetfs
City/Town of 0 6 2024
System Pumping Record MAY
-Form 4
DEP has provided this form for use by local Boards of Health. Other forfftt 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 back side rear left right
A, Facility Information BUILDING: front back side rear leh right
Important:when DECK: under
lilting out forms 1. System Location:
on the compulel,
use only the lab los ur1i
key to move your Address /n�
cursor.do not
use Ilse return N,./� AC Lx� MA key. cily/Town State Zip Code
2. S stem O ner;
4
r,a a( 2-1 A E
Name
r\nnm
Address (if different from location).
MA
cilyrrown Slate
Zip Code
3�1
Telephone Number
B. Pumping Record
1. Dale of In Pum •j�� f 2 l
p g l � 2• Quantity Pumped: /5M
Dale
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 condili n,of component p mped:
6. System Pumped By.-
Dave Tiney Mass'Fss82"1— Mass 1AA95E
Name Vehicle License Number
Baleson Enterprises, Inc.
Company
7, o on where contents were disposed:
GLSD
6It/Z,
Signature of Hauler Dale
Signature of Receiving Facility(or attach facility receipt) Dale
15form4,doc, 11/12
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