HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 40 SALEM STREET 10/31/2022 � Commonwealth of Massachusetts RECEIVED
w City/Town of
System Pumping Record OCT 312022
Form 4
TOWN EP
HEALTH DEPARTMENT
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 side rea a right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. Sy t Lo t,pjaion'
on the computer,
use only the tab v16 3_��_ F
key to move your A dr s �j
cursor-do not /Yzjw _ � '�( ��
use the return
it /Town State ZipCode
key. y
2. S stem Owner:
roD
Nam—
aemm
Address(if different from location)
City/Town State Zi Code
�al� �F�_ q:
Telephone Number
B. Pumping Record IF
t_d1_d2_
45�3�
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Ws6ptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): — -- --
4. Effluent Tee Filter present? ❑ Ye6;51 No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loc here contents were disposed:
LS
Zz 62
Signature of Ha r Date
1
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record •Page 1 of 1