HomeMy WebLinkAboutSeptic Pumping Slip - 60 Rocky Brook - Septic Pumping Slip - 60 ROCKY BROOK ROAD 10/1/2024 i
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of HQalth, Otfler forr115 may be U30d. bul the
informalion must be substantially the same as that provided hare. B9fore using this form, chock with your
local Board of Health to determine the form Ihey use, The System Pumping Record must be submltit d 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 ack side rear left right
A. Facility Information BUILDING: front back side rear left right
Imporlanf,when DECK; under
Illling oul forms I. System Location.,
on€he compuler, tt
use only the tab �� �1L GY.3 -
key to move your Address
cursor •do not U
use the ralurn .____ MA L
key. Alyrrown -- Stale
Zip Code
2. Syslam Owner;
Name
Address (if diff9renl from lo.calion) ---
_M A
CIIylTown — —
Slats Zip COc1a
I-3f Ste_
Te18owne Number
B. PUmping Record —�
1. Date of Bumping aarO 2, Quantity Pumped.
Gallons
3, Componenl: ❑ Cesspool(s) [� Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
. TTT I
5. Observed cond'(ion of component purnped.,
6. System Pumped By:
Dave Tine _ Mass 1AA95F Mass 1AD31Z�
Name Vehicle t icense umber ` —
Baleson Enterprises, Inc.
Company �� --
7. b�<�Vn where contents were disposed:
Signaluro o{Hauler
Signalu(a of Receiving 1_acillly(orettaeh facility receipt) Dale ~-- --
l5lorm4,doc, 11112
System Pumping Record . Pair; 1 D!1