HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 518 SALEM STREET 10/24/2023 Commonwealth of Massachusetts
City/Town of
System Pumping Record
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.
A. Facility Information
Left/Right front of house, Le /Right rear-.of house, Left/Right side of house, Under f'
Important:When
filling out forms 1. System Location: Left/Right side of building, /Right front of building, Left/Right rear of building,
on the computer, 4-/ % S
use only the tab
key to move your Address /� ��
cursor-do not I m+r 1/`h b MA U`
use the return City/Town State Zip Code
key.
2. System Owner:
C aLbn
Name
ierom .
Address(if different from location)
MA
City/Town State J � � Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ate 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 F5821 AT95Q
Name Vehicle License umber
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
I GLSD
16 2 .2?
Signature of Haul Date
Signature of Receiving Facility(or attach facility receipt) Date
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