HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 150 SALEM STREET 8/13/2024 Commonwealth of Massachusetts
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System Pumping Record AUG 1 �' ` 2k
Forn1 4 t
DEP has provided this form for use by local Boards of Health, Other forrrts�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: fronClacl side rear le rig�It
A. Facility Information BUILDING: fron side rear left rig
Important:when DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab t ez xt
key to move your Address
cursor-do not N ar / MA C3 ) LDS
key.
use the return Ci y/Town vV State Zip Code
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2. System Owne
� ct?
Name
inwn
Address (if different from location)
MA
Cityrrown State Zip Code
SZS- 32&- N57
Telephone Number
B. Pumping Record
1. Date of Pumping a I 2 2. Quantity Pumped:
Date 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 1AD31Z
Name Vehicle I-icense N tuber
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
(GILSD�
Signature of Hauler Date
Signature of Receiving acility(orattach facility receipt) Date
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