HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 TUCKER FARM ROAD 5/6/2024 Commonwealth of Massachusetts
City/Town of 6 2Q2�
System Pumping Record I�AY 0
Form 4
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DEP has provided this form for use by local Boards of Health. Other,fwTiei1r by 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 dale in
accordance with 310 CMR 15.351.
HOUSE: front back sid rea le right
A. Facility Information BUILDING: front back side rear leh right
Important:When DECK: under
filling out forms 1. System Location: S
use
they he tab, t f�k�� Vann 9 G use only the lab
key to move your Address
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use the return a " '� MA
key. Cilyrrown Stale
Zip Code
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2. System Owner:
Name
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Address (it diKerenl from location) .
MA
Cilyrrown Stale
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping pale 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) ,�J Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): /
4, Effluent Tee Filter present? ❑ Yes No It yes, was it cleaned? ❑ Yes ❑ No
5. Observed con Ition.of component pumped:
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6. System Pumped By:
Dave Tiney Mass Mass 1AA95E
Name Vehicle license Number
Baleson Enterprises, Inc.
Company
7, L alion where contents were disposed:
LS
hor 5-11 A y
Signalure of Hauler Dale
Signature of Receiving Facility(or attach facility receipt) Dale
15form4.doc- 11/12
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