HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 518 SALEM STREET 5/24/2024 Commonwealth of Massachusetts Nosh pna°�e�
City/Town of
a
System Pumping Record Mai 4102�
Form 4 t
M s�mer
DEP has provided this form for use by local Boards of Health. Other forms may,bPted 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�sideleft right
A. Facility Information BUILDING: fronteft right
Important:when DECK: under
filling out forms 1. System Locati n:
on the computer, c
use only the tab
key to move your Ad ress
cursor-do not .k,1(' / MA 61 w
use the return City/Town State Zip Code
key.
2. S StC� Owner,r� c
ct-
Name
reran -
Address(if different from location)
MA
Clty/Town State Zip Code
Telephone Number
B. Pumping Record
/o�
1. Date of Pumping Date2! Z 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.
/0o r'4 .
6. System Pumped By:
Dave Tiney _ _ ass 1AA95E M AD 1Z
Name V hicle License b
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
GLSD
— 52r2
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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