HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 90 WINTERGREEN DRIVE 5/6/2024 Commonwealth of Massachusetts r
City/Town of
' System Pumping Record AY p62024
Form 4
DEP has provided this form for use by local Boards of Health. Other forrns'MhAy`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 ac side rear left rig
A. Facility Information BUILDING: front back side rear leh right
Important:When DECK: under
filling out forms 1. System Locati n:
on the computer, O C3,11
�� e
use only the lab
key to move your Ad ressA `
cursor•do not N -� t ,� MA �( c fS
use th rn e retu ♦w ly`f'-7
key. CilyfTown Stale Zip Code
,b 2. System Owne
kIx
Name
r\
"r
nnm
Address (it diHerenl from location).
MA
CilyrTown Stale
W-- -( 6- 5Hdlp Code
Telephone Number
B. Pumping Record �/
1. Dale of Pumping -I [3D'21 1'5M
Dale 2. Quantify Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? Yes ❑ No It yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped: !T
Q OA4
6. System Pumped By: iiMZ,
Dave Tiney Mass-E-11B-�-t Mass 1AA95E
Name vehicle License Number
Baleson Enterprises, Inc.
Company
7, at ion where contents were disposed:
GLSD
cl
Slgnalure'ol Hauler - - - ---- -
Date - --
Signalure of Receiving Facility(or attach facility receipt) Date
15form4,doc• 11/12
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