HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 437 SALEM STREET 5/6/2024 etts
Commonwealth of Massachus F -
City/Town of
System Pumping Record 06ZU4
Form 4
DEP has provided this form for use by local Boards of Health. Other f Fms may be used, but the
information must be substantially the same as that provided here. Be�9e 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 dale in
accordance with 310 CMR 15.351.
HOUSE: front bac side rea le right
A. Facility Information BUILDING: front Pack side rear left right
Important:When
DECK: under
filling out forms 1. System Location:
on the computer, �� (�
use only the lab 1 T Jl/t J
key to move your A dre
cursor•do not
use Ilse return _ �A��R� MA Q l�
key. Cily/Town Stale Zip Code
2. System Owner:
Name
nnm
Address (if difterenl from location) .
MA
cityrrown Slate Zip Code
Telephone Number
B. Pumping Record
1. Dale of Pumping Date 2� 2. Quantity Pumped: 1QUG
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:
(-AAA
6. System Pumped By: 1311-�z
Dave Tiney Mass brE9'g1 Mass 1AA95E
Name Vehicle License Number
Baleson Enterprises, Inc.
Company
7, Nalion where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility(o(allach facility receipt) Dale
15form4,doc- 11/12
System Pumping Record -Page 1 of i