HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 76 EVERGREEN DRIVE 5/6/2024 s r
Commonwealth of Massachusetts
City/Town of MAY 4 6 2024
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 back side rear leh right
A. Facility Information BUILDING: front ck side rear leh right
Important:When DECK: under
tilling out forms 1. System Location:
on the computer.
use only the tab
key to move your Address
cursor-do not J.A MA
x G(�yS
use the return -
key. CityrTown Slate Zip Code
2. System Owner:
ra rr II
_ U2 Fi�nt'
Name
nnm
X I
Address (i(different from location).
MA
cilyrrown Slate
Zip Code
Telephone Number
B, Pumping Record
�o 1
1. Dale of Pumping vale 2• Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No 11 yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By: l A D31Z
Dave Tiney Mass -!5r8�Ti- Mass 1AA95E
Name Vehicle License Number
Baleson Enterprises, Inc.
company
7. Location where contents were disposed:
GLS
0
gl,?o�`1
Signature of Hauler Dale
Signature of Receiving Facility(o(allach facility receipt) Dale
15form4,doc- 11/12
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