HomeMy WebLinkAboutSeptic Pumping Slip - 42 Fuller - Septic Pumping Slip - 42 FULLER ROAD 9/23/2024 I
Commonwealth of Massachusetts
City/Town of
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 submMed to
the local Board of Health or other approving authority within 14 days from he purnping date in
accordance with 310 CMR 15.351, - 1
HOUSE: front back side rea le ' right
A. Facility Information BUILDING: rout back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on Iha computer, C ) G{ {
use only tho tab L r(- G
key to move yqur Addross�y
Cursor.do not
use the return MA
key. CltyfTown Stale zip Code
2, System Owner;
Name
Address (If different from location) I
MA _
Cliy/TownTm v Slate Zip Cods
_ Telephone Number
B, Pumping Record
1. Date of Pumping2 � ?� 2, Quantity Pumped: �5W
Y peci:p${s Gallons
E
i
3, Component'. ❑ cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filler present? ❑ Yes NO If yes, was it c#eaned? ❑ Yes ❑ No
5, Observed condition of component pumped:
G. System Pumped By:
Dave Tine Mass 1AA95E Mass 1AD'
Name vehicle License
Baleson Fnlerprises, Inc.
Company
7. L n where contents were disposed:
Otio _
Signature of Hauler Dale
Signature of RecelvingTFacility(o€atiach facility receipt) Ogle r
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