HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 450 BOSTON STREET 4/8/2025 OPX/7
Commonwealtr� of Massachusetts Of Nolthn
doVer
City/Town of
~� System Pumping Renard Ap 142025
;r Form 4
DEP has provided this forma for use by local Boards of Health. Other forms may �`"PQI the
information must be substantially the same as that provided here. Bpfore using this fornl, with your
local Board of Health to deterrnine the fornr they use. The System Pumping Record must be submitted to
the local Board of Health or other approving aulhorit'y within 14 days from 'he purnping date in
a c c(:)r d a n c e with 310 C M R 15,351, -----.--- _.
HOUSE: front back side rear le rigI
A. Facility Information BUILDING: front back side ar left rig;
mportant;When DECK: under
t Mling out forms 1. Systern Location.
on the computer,
use only the tabs' —
key to move your A dress
cursor-do no(
use the return _ ..,____ _ _-- --__ —__` _-_---._._._.._..__.______..._...__. _ (V A ---- --�--- _..
ke ciiyrrown sta te Zip Code
Y
2. S tern Owner:
I
r
� - LA
ronrn `�
Addross (if dif-feroot fforn location)
MA
c — _
Y alale_ .{"�/ � �l 7 Z( C dr
rele hone Number p r
B. Pumping Record ---
1. Date of Pun'iping , Quantity Pumped
i Gallons
f
3. Component: ❑ Cesspool(s) epti c `r Tight Tank ank ❑ Ti
d g ❑ Grease Trap
f
l
i� Other (describe):
f ►_�
4. Effluent Tee Filter present? t Yes ❑ No If yes, was it cleaned? es 6 No
t
5. Observed condition of component pumped:
r
& System Pumped By.
Dave TineY .. _..__ Mass 1AA95E Mass 1AD31Z
i r4airrr; Vr Yvrlc. LlCen,,r, NurnbPr
Balesan Enterprises, Inc
Company
7. Location where contents were disposed:
GLSD
signalure of Hauler Date
t
ylyirt�lurry of (-;r.cewing f-aciVily (ur ,aUsrr�t� larility rer;cir>t) (7a(e
1
15forrn4.06c' 11112 System Pumping Record- Page 1 of 1