HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1276 SALEM STREET 1/31/2022 : 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 you
local Board of Health to determine the form they use. The System Pumping Record must be submitted tc
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left]Right , Left/right side of house, Left
Right side of building, Left/Right front of building, Le /Right rear 6 uiiding, Under deck
on the computer.
use only the tab
key to move your des
cursor-do not �A)(f,,< G L MM N 3 ,,
use the return own -
key. tY rOwN3tate �� Zip Code
2. System Owner: HRH o H p)pAa MEN DER
Name
Address(if different from location)
MA
Citylrown Sta Zip Code
�3 -s 2,
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) *Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe).-
-- _
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumpe B;:4.
Jon Kirmil / /�?� Mass F5821
Name Vehicle License Number
Bateson nterprises, Inc. _
Company
7. Lo here contents were disposed:
GLSD 71owell Waste Water
Signature of Hauler Date