HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 506 SALEM STREET 5/8/2023 IC
x Commonwealth of Massachusetts RE��ivE�
City/Town of
a System Pumping Record ��py o $'�J2�
Form 4 O9TH AN��
TOW�N� D��MENj
DEP has provided this form for use by local Boards of Health. Othil ormTHs may be used, but the
information must.be substantially the same as that provided here. Before using this form, check with y
local Board of Health to determine the form they use. The System Pumping.Record must be submitte
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CM 15.351.
— HOUSE: Gnt back side rear ri€
A, Facility Information BUILDING: front back side rear left rig
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, rev^ CSmac.1 e M S use only the lab �`�b
key to move your Address
cursor-do not N Nn�bVe— Of �
use the return City/Town Stale Zip Code
key.
2. System Owner:
Name
n4an
Address (if different from location)
City/Town . State ip ode
Rids
Telephone Number
B. Pumping Record
1. Date of Pumping Date S 2. Quantity Pumped: �s
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 of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. ntion where contents were disposed:
/ Z
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Dale
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