HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 2050 SALEM STREET 11/21/2023 Commonwealth of Massachusetts .� ��'✓
bty/Town of
a
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, Left fight rear of house, Left/Right side of house, Under[
Important:When
filling out forms 1. Sy tem L cation�Left/n/R' ht side of building, Left/Right front of building, Left/Right rear of building,
on the computer,
use only the tab v V
key to move your XddressC�G
cursor-do not _�I�IW,�{., MA
use the return City/Town State Zip Code
key.
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2. Sy m Owner:
me
rxan
Address(if different from location)
MA
City/Town State !/ Zip Code
Telephone Number
B. Pumping Record
X� '—\ 2. QuantityPumped:
I. Date of Pumping Date p Gallons
3. Component: ❑ Cesspool(s Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): — —
4. Effluent Tee Filter present? ❑ Y 4 o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumpe
6. System Pumped By:
Dave Tiney Mass F5821 1AA IM 95
Name Vehicle License Q umber
Bateson Enterprises, Inc.
Company
7. Loc w e contents were disposed:
GLSD
Signature of Hau ate
Signature of Receiving Facility(or attach facility receipt) Date
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