HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1499 SALEM STREET 6/10/2024 \ Commonwealth of Massachusetts
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City/Town of
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System Pumping Record UN 1 Q 2024
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 ac ide rear left right
A. Facility Information BUILDING: front back side rear left right
Important:when DECK: under
filling out forms 1. System Location,
on the computer, /
use only the tab
key to move your Address
cursor-do not i) _ ���� MA
use the return Cil own
key. � State Zip Code
2. S� em Owner:
rab }t > , ,
Name --
num
Address (if different from location)
MA
Cityrrown State ZI Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2 K34
P 9 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 condi ion of component pumped:
6. System Pumped By:
Dave Tiney Mas 1AA95E Mass 1AD31Z
Name Vehlc License ber
Bateson Enterprises, Inc.
Company
7. 1 oration where contents were disposed:
(7)
LS
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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