HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1260 SALEM STREET 11/21/2023 Commonwealth of Massachusetts
w �a City/Tow
System Pumping Record pV �l,toti�
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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 ba side rear le right
A. Facility Information BUILDING: front back e rear left
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Ad s
cursor-do not k 1 f MA s
use the return cityfrown State Zip Code
key.
2. System Owner:
Name
renm
Address(if different from location)
MA
City/Town State (� [�Ziipp Code
Telephone Number
B. Pumping Record
1. Date of Pumping D- 6a e 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 p mped:
6. System Pumped By:
Dave Tiney MassG'cens
Mass 1AA95E
Name Vehicleumber
Bateson Enterprises Inc.
Company
7. tion where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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