HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 136 CARLTON LANE 5/6/2024 Commonwealth of Massachusetts
City/Town of Zak
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Othlsr-forr:ris 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 dale in
accordance with 310 CMR 15.351.
HOUSE: Pront
back side rear eft ight
A. Facility Information BUILDING: back side rear leh right
Important:When DECK: under
filling out forms 1. System Location:
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2. System OwVD- ner:
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Name
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Address (if diHerenl from location) .
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Zip Code
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Telephone Number
B, Pumping Record
1. Dale of PumpingG' I!
Dale L 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filler present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
GVafr"�c
6. System Pumped By: A%
Dave Tiney Mass F-5827— Mass 1AA95E
Name Vehicle License Number
Baleson Enterprises, Inc.
Company
7. lion where contents were disposed:
GL IS,D
Signature of Hauler Dale
Signature of Receiving Facility(o(allach facility receipt) Dale
15form4,doc- 11/12
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