HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 150 SALEM STREET 8/29/2022 Commonwealth of Massachusetts
City/Town of P�G2g2�titi o��a
System Pumping Record ,NANO l
Form 4 �OW00V ve Sol
NEA
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: front back 6-1cle rear left igh
A. Facility Information BUILDING: front back side rear left right
Important:When s DECK: under
filling out forms 1. System Location:
on the computer, a�2 V,\
use only the tab
key to move your Address
cursor-do not N, 4&
use the return -- -- - ----- -- -- -
key.
City/Town State Zip Code
2. System Owner:
nb
RC�
Name
ie�mn
Address(if different from location)
City/Town r/ 7Sla,)e �I ^� Zip Code
Telephone Number vn(
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) �SepCicTank ❑ 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.
'41d I-&I
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Signature Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date —
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