HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1432 SALEM STREET 6/17/2024 Commonwealth of Massachusetts ,�Go�
City/Town of �o�
System Pumping Record v"� ti
;F Form 4 erti
�M
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: ron ack side rear le rig
A. Facility Information BUILDING: front back side rear left right
Important:when DECK: under
filling out forms 1. �ystem Local
on the computer,
use only the tab
key to move your Address
cursor-do not MA
use the return u 1,44
key. ity/Town State Zip Code
2. ystem Owner:
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Name /y�vj
renrn
Address(if different from location)
MA
City/Town State � Zip Code
Telephone Number
B. Pumping Record 1()5j
1. Date of Pumping Date 2_ Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) eptic 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 1AA95 Mass 1AD31Z
Name Vehicle License umber
Bateson Enterprises, Inc.
Company
7. Loc on whe contents were disposed:
LSD
Signature of Hauler UZ Date
Signature of Receiving Facility(or attach facility receipt) Date
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