HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1440 SALEM STREET 12/21/2023 Commonwealth of Massachusetts
City/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.
HOUSE: front back side rear left right
A. Facility Information BUILDING: front back side rear left right
Important:When
DECK: under
filling out forms' 1. System Locae
ion:
on the computer, 7 1�
use only the tab 7 1 rr
key to move your Aoress
cursor- not �oU-t� MA 4I kL)5—
use the return
urn Cit /Town
key. y State Zip Code
2. System Owner-
Name
nnm
Address(if different from location) .
MA
City/Town State Q Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: L5W
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present/onent
Yes ❑ No If yes, was it cleaned? [�Yes ❑ No
5. Observed cc dition of co pumped: /
9v cM .
6. System Pumped By:
Dave Tiney _ Mass F5821 Mass 1AA95
Name Vehicle License N ber
Bateson Enterprises, Inc.
Company
7.9GLS ,
on where contents were disposed:
al6h)
Signatutfe of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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