HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 208 CARLTON LANE 5/6/2024 Commonwealth of Massachusetts
City/Town of E� Y ® G 2U4
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms 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: front righ
ba side rear left t
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on Ilse computer, 1 L
use only the lab Zak Cam-
key to move your Address
cursor-do not �+
use Ih + �dV � MA ifs q/
e return � �� 15—
key. Cityrrown State Zip Code
2. System Owner:
r�
Uss, rib C-7►h6ry
Name
r�nnrn
Address (i(different from location) .
MA
Cilyrrown Stale
Zip Code
Telephone Number
B, Pumping Record
1, Dale of Pumping Date 1�30A 7 2. Quandly Pumped: �S
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): ,_.f
4. Effluent Tee Filter present? ❑ Yes I /I No It yes, was it cleaned? ❑ Yes ❑ No
5. Observed condilio i.of component pumped:
It.�rMs
i
6. System Pumped By: 131q�
Dave Tiney Mass f •1- Mass 1AA95E
Name Vehicle license Number
Baleson Enterprises, Inc.
Company
7. L anon where conienls were disposed:
GLS
ff — a 2
Signature of Hauler Date
Signature of Receiving Facility(or allach facility receipt) Date
15form4.doc, 11/12
System Pumping Record Page 1 of I