HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1510 SALEM STREET 8/13/2024 Commonwealth of Massachusetts
City/Town of
System Pumping Record
? 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-he pumping date in
accordance with 310 C M R 15,351.
HOUSE: front Gac side rear left righ
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 sil'a SASV
key to move your Address
cursor-do not MA 4��
use the return Cit !Town
key. y State Zip Code
2. System Owner:
VI 11�
Name
nian
Address(if different from location)
MA
City/Town Stale Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Deb 2. Quantity Pumped: Gallon` s v
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 p mped:
6. System Pumped By:
Dave Tiney Mass 1AA95E Mass 1AD3
Name Vehicle License Nu bar
Bateson Enterprises, Inc.
Company
7. non where contents were disposed:
tA
Signat— u�t�1 Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc- 11112 System Pumping Record•Page 1 of 1