HomeMy WebLinkAboutSeptic Pumping Slip - 29 Colonial Dr - Septic Pumping Slip - 29 COLONIAL AVENUE 9/18/2024 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, bul the
information must be substantially the same as that provided here. Rnfore 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 15,361,
HOUSE: front back side ear left' Q62g
A, Facility information BUILDING: front back side rear left
Important:When DECK: under
III{Ing out forms I. System Location
on the computer, [[
use only the lab 2 Co fan tc,1 r'
key to move your Address
cursor-do not
use the velum MA Q
key. Chyliown a Stale ZlpCode
2. S stem Owner;
P,( Name
Addles {Ir d}flerenl Irom localionj
_ MA _
CIIylTown Stale ZIP Code
33r -3 O(�a� _
Telephone Number
B. Pumping Record �( -
1. Date of Pumping ly P 2. Quantity
. ale uniped; Galtons
I 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 pumped:
6. System Pumped By:
Dave TineY _ass 1AA9Mass 1AD31z
Name Vehicle Llcans mbar
Ba(eson Enterprises,
Company
7, ion where contents were disposed,
GL50
Signature a, Hauler Dale
Signature or Recaiuing Ij la IIG If la Iic y(or at4ach facility receipt) Date ~—�
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