HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 437 SALEM STREET 4/25/2023 -4\ Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record XpR 2 520D
Form 4
1� ORTH A®b DEPARTMENTS
DEP has provided this form for use by local Boards of Health. Other orms 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 Syste.m 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(leb right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Locatic
on the computer, qQ � L
use only the tab 1�J �T
key to move your A dres
cursor-do not S_� ,Q/ ,/�Cl
use the return City/Town State Zip Code
key.
2. S st Owner:
.o C,MMat�
r
Name
lNmll '
Address(if different from location)
City/Town . State Zip Code
Telephone Number
B. Pumping Record
1, Date of Pumping Date 2. Quantity Pumped. —
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition f component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L tion where contents were disposed:
GLSD
4.b d
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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