HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1925 SALEM STREET 8/7/2023 Commonwealth of Massachusetts
Q. City/Town of If
�
System Pumping Record ��N°
Form 4 a
M
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 ide rear Eright
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. S Ste k� ,
on the computer,
use only the tab - - ---
key to move your A ress
cursor-do not AJ MA
use the return City/Town State Zip ode
key.
2. System Owner:
Name
ftqt�- �;Je,
Address(if differe t from location)
MA
CitVTTown State Zi ode
Telephone Number
B. Pumping Record
1. Date of Pumping 1�3- — 2. Quantity Pumped. Gau/5�
Date
3. Component: ❑ Cesspool(s) [� Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): --- - -- _ - -
4. Effluent Tee Filter present? Ye o If yes, was it cleaned? Yes ❑ No
5. Observed condition :
of component umped
1 ) nA
6. System Pumped By:
Dave__Tiney as F5821 Mass 1AA95E
Name Vehic Licens umber
Bateson Enterprises, Inc.
Company
7. oc *on where contents were disposed:
GLSD _
Signature of uler Date
Signature of Receiving Facility(or attach facility receipt) Date
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