HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1440 SALEM STREET 12/12/2022 gECEIVI;';'
Commonwealth of Massachusetts GEC 1 �,2022
City/Town of
TOWN O�NO`rl7H AIUDOVEFi
System Pump i n g Record HEALTH DEPARTMENT
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 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 sid re eft right
A. Facility Information BUILDING: front back side rear left right
Important:When
DECK: under
filling out forms 1. S stemLocation: /
on the computer, /S ` /�,.,_
use only the tab C/ �J iiivvv�'/�,�ft
key to move your Address
cursor-do not W61? k/'/
'�use the return it /Town
key. y tale Zip Code
2. stem Ow er:
Dra
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Name
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Address(if different from location)
City/Town Slat Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank g ❑ Grease Trap
❑ Other (describe): —
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned?/ 4es ❑ No
5. Observed condition of component pumped-
.
r -
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loc ion where contents were disposed.
L
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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