HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1592 SALEM STREET 10/2/2023 Commonwealth of Massachusetts
City/Town of
System Pumping Record
w Form 4
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 side rear left right
A. Facility Information BUILDING: ont back side rear left right
DECK: under
Important:When
filling out forms 1. System Location
on the computer, c �
use only the tab 07— �3+ 111���..
key to move your Address
cursor-do not /`[ _ MA
use the return Cityfrown State Zip Code
key.
2. System Owner: •
CV/1 -
Q_=���� Name — T -------
Address (if different from location)
MA
City/Town State�`Q q /�[Z'iipp Code
Telephone Number
B. Pumping Record
OCCG
1. Date of Pumping pate -- 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 condi ion of component pumped:
6. System Pumped By:
Dave Tiney Ma F582 Mass 1AA95E
Name Vehic icen umber
Bateson Enterprises, Inc.
Company
7. L �on where contents were disposed:
LSD _ -- --
_A2:A�3 _ ---
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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