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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 444 SALEM STREET 4/3/2023 Commonwealth of Massachusetts RECEtVEG City/Town of System Pumping Record Form 4 'TOWN HE LTH�DEE,PARTM EN 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 rear le right A. Facility Information BUILDING: front back side rear left right Important:When DECK: Under filling out forms 1. System Location: on the computer, he tab, VW ��/n 5 use only the tab �'�/ key to move your Add//(//'rpss cursor-do not 69 f use the return ity/Town State Zip Code key. 2. System Owner: IsD i Name man ' Address(if different from location) City/Town . State Zip Code Q / - ©/0 Telephone Number B. Pumping Record ``�/ 1. Date of Pumping `' �D 2. Quantity Pumped: - 6) Date Gallons 3. Component: ❑ Cesspool(s) / Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): - -- 4, Effluent Tee Filter present? ❑ Yet�/_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 i Company 7. Loc here contents were disposed: LSD y Signature of Ha Date l{ Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc 11/12 System Pumping Record•Page 1 of 1 i a r