HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 474 SALEM STREET 10/2/2023 Commonwealth of Massachusetts
City/Town of
7
System Pumping Record pC� o�1oti
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 rea left fight
A. Facility Information BUILDING: t back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, � -\i C
use only the tab Lo� J��e M S
key to move your Address
cursor-do not ►y __J_ _ _ MA Q f
use the return CitylTown State Zip Code
key.
2. System Owner:
Name
iron - --
Address(if different from location)
_ MA _ _
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping —�a --- 2. Quantity Pumped: S �
Date 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 con ition of co ponent pumped:
6 System Pumped By:
Dave Tiney _ Ma rsF5821 Mass 1AA95E
Name Vehi License umber
Bateson Enterprises, Inc. _
Company
7. tion where contents were disposed:
GLSD
- g 1�Iz3
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Dale
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