HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 66 COLONIAL AVENUE 6/10/2024 {�:���14
\ Commonwealth of Massachusetts
City/Town of JUN 1 2024
System Pumping Record
a Form 4
ky�,.6.n�J
_ ,. ,.i�: t
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: Pfron back side rea left right
A. Facility Information BUILDING: back side rear left right
Important:when DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab �-
key to move your Address
cursor-do not t ` '�,, �
use the return �N�.o � � ��1 MA 4t zs-
key. y State Zlp Code
2. System Owner:
G(-'e r K�'
Name
noun
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B, Pumping Record
1. Date of Pumping Date 2• Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): — --
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pu ped:
Ly-s_�A'I
6. System Pumped By:
Dave Tiney Mass 1AA95 Mass 1AD31Z
Name Vehicle License tuber
Bateson Enterprises, Inc.
Company
7. L c 'on where contents were disposed:
GLSD /
Signature of Hauler _ Date
Signature of Receiving acility(or attach facility receipt) Date
t5form4.doc- 11112 System Pumping Record•Page 1 of 1