HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 40 SALEM STREET 7/29/2024 Commonwealth of Massachusetts 1OR. Jc � A�do`{er
City/Town of 9 z024
System Pumping Record Jul-
Form 4
rtn�ent
DEP has provided this form for use by local Boards of Health. Others"may be sed, 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 back side side rear lefteIgzt
A. FacilityInformation
mation
BUILDING: front back side rear left
Important:when DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab Q
� 54 l r, S*
key to move your Address cursor•do not ,AnAoL—,— MA (���
use the return
key. CitylT own State ZIP Code
2. System Owner:
RI� II I
Name
nrWn
Address (if different from location)
__ -- MA
cityrrown Slate Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date LS 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 ass 1AD31Z
Name Vehicle license Numb r
Bateson Enterprises, Inc.
Company
7. nfion where contents were disposed:
Signature df Hauler Dale
Signature of Receiving Facility(orattach facility receipt) Date
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