HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 270 SOUTH BRADFORD STREET 5/6/2024 Commonwealth of Massachusetts
City/Town of �,4AY 06 2C24
System Pumping Record
Form 4 a z l
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 date in
accordance with 310 CMR 15.351.
HOUSE: front back side rear le right
A. Facility Information BUILDING: Pont back side rear leh right
Important:When DECK: under
filling out forms 1. Syslern Localion:
usethe computer he tab' L�
use only the lab C
key to move your Ures
cursor •do not th )c, C MA
use e return �� _ K'�wf3
key. Cilyrrown State Zip Code
2. System Owner:
SW �-
Name
nnrn
Address (if diHerenl from location).
MA
city/TownSlate
Zip Code
Telephone Number
B, Pumping Record
1. Dale of Pumping /�� 2 2. Quantity Pumped: /`S
Oale y p Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes P No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condilion.of component pumped'.
6. System Pumped By:
Dave Tiney Mass F-S&?-r Mass 1AA95E
Name vehicle License Number
Baleson Enterprises, Inc.
Company
1. a ion where contents were disposed:
GLSD
a� HaoZ
Signature of Hauler Dale
Signature of Receiving Facility(o(atlach facility receipl) Dale
15form4•doc- 11/12
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