HomeMy WebLinkAboutSeptic Pumping Slip - 133 Colonial - 10/24/2024 - Septic Pumping Slip - 133 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: fronlj� back si ...real' left right
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
key to move your A dress MA
cursor-do not
use the return
key. City[Town State Zip Code
2. System Owner:
M6 (-,c
Name
Address(if different from location)
MA
City/Town State Zip Code
-te—leph—one-
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
DateGallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E 4��ass-TAMTt--,,,
Name Vehicle License
Bateson Enterprises, Inc.
Company
7. ;tion where contents were disposed:
GLSD
Signature of Ha7ui;-r--- bate
�ignatureT&CikiFci�Mii-� Facilityii (or aEach facility receipt) Date
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