HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 507 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 LocatioRig front of hoes 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
Address
Citylrown State Zip Code
2. System Owner. &rc-e�
Name
Address(if different from location)
Citylrown State Tp Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? [�t'es a❑ No
5. Condition of System:
6. System Pumped y:
F5821
Name Vehicle License Number
Batescn Enterprises Inc
Company
7. Locati here content were disposed:
G L S. A J Lowe a e Water
Signiftie 9t Haul Date
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