HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1550 SALEM STREET 11/4/2022 Commonwealth of MassachusettsECE,vE��
City/Town of _
System Pumping Record
Form 4 5H A�ppv'`
OF NpEPAR�MENj
DEP has provided this form for use by local Boards of Health. OtheYOtms 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: <Pback side rear left i�Y'e1it�
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, ` e `
use only the tab 1 'T
key to move your "—ddresk55—cursor-do not
use the return
key. City/Town
State Zip Code
2. System Owner:
VQ e SS1,t^f+ CC, t'
Name --
rnwn
Address(if different from location)
City/Town State
Zip Code
7 3v ?_6g0 y
Telephone Number
B. Pumping Record
1. Date of Pumping I t t �� 1 �
Date 2. Quantity Pumped: Canons
3. Component: ❑ Cesspool(s) '_-11�eptic Tank
❑ Tight Tank El Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned?
❑ Yes ❑ No
5. Observed condition of component pumped:
/ /of/tI-- (
6. System Pumped By:
Dave Tiney Mass ss 1AA95E
Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
LS
Signatur Hauler `
Date
Signature of Receiving Facility(or attach facility receipt) Date
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System Pumping Record•Page 1 of 1