HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 58 SALEM STREET 9/6/2024 Commonwealth of Massachusetts y.
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may 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 CMR 15.351.
HOUSE: front back sid rea le t
A. Facility Information BUILDING: front back side rear left rt
Important:when DECK: under
filling out forms 1. System Location:
on the computer, Q S/)f�tl_,_�►'+ /
use only the tab o �..
key to move your Address A
cursor-do not AAA
MA gyp/
use the return (t !Town
key. y State Z(p Code
2. S Owner.
,.
Name
n�an
Address (if different from location)
MA
City/Town State 62n
09
, ZIy�Code
Telephone Numberl[�GI/
B. Pumping Record �—4�) '
1, Date of Pumping J�
p 9 Date VA 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Ye No If yes, was it clewed? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E ass�1AD31Z
Name Vehicle License Nu r
Bateson Enterprises, Inc.
Company
7. ation ere contents were disposed:
GL 09
Signature r Date
Signature of Receiving Facility(or attach facility receipt) Date
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