HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 506 SALEM STREET 11/2/2021 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 submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Locatio Le�, front of hou „Left/ Right rear of house, Left/right side of house, Left
Right side of building, Left/ Right front of building, Left/Right rear of building, Under deck
use only the tab - - --- -
key to move your Address
cursor-do not
use the return City/Town State Zip Code
key.
2. System Owner:
0(c Ca
Name ,
mtm
Address(if different from location)
City/Town Stat Q n 4D Cpda-
S
Telephone Number �(O• `�
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): -
4. Effluent Tee Filter present? ❑ Yes �No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed con itio of componen pump d- '
6. System Pumped By•
NangATESON ENTERPRISES,INC. Vehicle License Number
111 ARGILLA ROAD
ComphA IDOVERU,Ifiwolalo —
7. Location where contents wire d�rNsed:
-- - - --- -
Signature of a Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1