HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1116 SALEM STREET 10/31/2022 t
Commonwealth of Massachusetts
�ECEIVEU .
City/Town of
R System Pumping Record �� 312022
Form 4 oovEP
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DEP has provided this form for use by local Boards of Health. OtherT9qM41 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 ac side rear el�right
A. Facility Information BUILDING: front back side rear left right
Important:When
DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab 1/YI �
key to move your Addre ,^
cursor-do not T/J'
use the return City/Town
key. State Zip Code
2. System Owner:
iw
i 4
Name
ie�mn
Address(if different from location)
City/Town State Zip Code
Tel hone Number
B. Pumping Record
1. Date of Pumping ate 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) A5eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): ------ -- --- - _ —_-- —__--—--
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? El Yes 7 No
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1 5. Observed condition of component pumped:
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6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
I Bateson Enterprises Inc
l
j Company
7. L n where contents were disposed:
GLSD
I
Signature of Hauler Date
I Signature of Receiving Facility
(or attach facility receipt) Date
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System Pumping Record•Page 1 of 1
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