HomeMy WebLinkAboutSeptic Pumping Slip - 1225 Salem St - Septic Pumping Slip - 1225 SALEM STREET 9/25/2024 fi
Commonwealth of Massachusetts
City/Town of _
_ System Pumping Record
i
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, chock with your
local Board of Health to determine the form [hey use. The System Pumping Record must be submltted to
the local Board of Health or other approving authority within 14 days from -he pumping date in
accordance with 310 GMR 16.351. --.
HOUSE; front back si e rear to����rl h��
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A. Facility Information 81JU)ING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location'
on the computer, l r
use only the tab I
key to move your ddras-s
cursor-do not .J / MA
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use the return G 1� �1��i`_ —
key. CllylTown Sfele Zip ode
2. System Owner:
Name
16
R
Address (If different from tocatlon) m_-
MA
Glly(Town _ Slate
Telephone Number —
B, Pumping Record
1, Date of Pumping C 2 Quantity Pum ed: X
Date y p Gallons
3. Component: ❑ Cesspool(s) / Septic Tank ❑ Tight Tank ❑ Grease Trap
El Other (describe): — (
4. Effluent Tee Filter present? ❑ Yes No If yes, was It cfeaned? ❑ Yes ❑ No
5. Observed condition of component pumped: /
6. Systern Primped By:
Dave Tiney _ Mass 1AA95t= Mass 1AD31Z
Name Vehfcle License Number
Baleson Enterprises, tOc.
Company
7, Location where contents were disposed:
Gt_SD
Signature of Harder Data
Signature of Reoeiving Facffily(or attach facility recefpt) Date
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