HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1510 SALEM STREET 5/8/2023 y FEGE��
Commonwealth of Massachusetts
City/Town ofo
System Pumping Record NOFNORT"P`` 1
T M
{ Form 4 �OHEAC-fHD�PAy
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 ye
.local Board of Health to determine the form they use. The System Pumping.Record must be submitted
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 (2)sid rea left righ
A, Facility Information BUILDING: front back side rear left righ
DECK: under
Important:When
filling out forms 1. System Location.
on the computer,
use only the tab �10
key to move your Addr ss
cursor-do not -Y v A n f Q' t�
use the return City/Town Stale•� Zip Code '1'
key.
2. Syste Owner:
Name
urwn
Address (if different from location)
City/Town . State Zip Code
a
Telephone Number
B. Pumping Record
1. Date of Pumping Da1 Z Z 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 of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L ation where contents were disposed:
GL D
Signature ol Hauler Dale
Signature of Receiving Facility(or attach facility receipt) Date
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