HomeMy WebLinkAboutSeptic Pumping Slip - 145 Colonial Dr - 10/24/2024 - Septic Pumping Slip - 145 COLONIAL AVENUE 10/24/2024 Commonwealth of Massachusetts
City/Town of
I 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 date in
accordance with 310 CMR 15.351.
HOUSE: front oa�c side rear left
A. Facility Information BUILDING: front back side rear left right
Important;When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab I ci,t-llk
key to move your Address
cursor-do not MA
use the return kl-A0A --
key. Cityi7own State Zip Code
Q2. System Owner:
Address(if different from location)
MA
Cityfrown State Zip Code
-fe—lep6—one
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: 7 Cesspool(s) Septic Tank M Tight Tank 7 Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? ❑ Yes 7 No
5. Observed condi f component pumped:
6. System Pumped By:
1>
_gave Tines Mass 1AA95E/,- Mass 1AD31,Z,
Name Vehicle License WwA;ar-��
Bateson EnterLrLses, inc.
Company
7. ion where contents were disposed:
GLSD
10
Signat I ure of Hauler Date
ReceivingSignature of cility(or attach facility receipt) Date
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