HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1895 SALEM STREET 5/13/2024 r\ndover
Commonwealth of Massachusetts
City/Town of 2024
a
System Pumping Record MAY 13
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 bac ide rear left righ
A. Facility Information BUILDING: front c side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, Ih� S'I_ A-
use only the tab �{y
key to move your Address
cursor-do not P ,N"�'Lue/ MA 04�Lis
�
use the return City/Town State Zip Code
key.
VQ 2. System Owner:
Name
rerun
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
5�
1. Date of Pumping Date — 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 1AA95E Mass 1AD3
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1