HomeMy WebLinkAboutSeptic Pumping Slip - 1348 Salem St - Septic Pumping Slip - 1348 SALEM STREET 9/19/2024 i
Commonwealth of Massachusetts
City/Town of `�
} Systern Pumping Record
Fornin 4
I
DEP has provided this form for use by local Boards of Health. Other farms may be used, but the
information must be substantially the same as chat provided here, Before using this form, chock with your
local Board of Health to determine the form they use. The System Pumping Record must be submMed to
the local Board of Health or other approving authority within 14 days from 'he pumping date in
accordance with 310 CMR 15,351.
HOUSr: front back side rear left ri6h
A. Facility Information BUILDING: r'ont back side rear left right
Important.when DECK', under
f1111ng out forms 1. System Location:
on the computer,
use only the lab j
key to rnova your Ad rase
cursor_do not }- Il CX 'r� MA
use the return Cfl ITown
key. Y slate ZIP Code
2, System Owner:
tA Q—
lrluR
Address (If different from locatlon)
MA l
Cily/Town _ Sla(emm Zip Code
Telephone Number
B, Pumping Record
1. Date of Pumping ! 1 2 L
! 9 Date 2. Quanitly Pumped:
-Gahons
3. Component, ❑ Cesspool(s) Septic Tank ❑ 'fight Tank ❑ Grease Trap �
❑ Other (describe):
4. Effluent fee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. Sy5lert-1 Pgrn.ped By:
_Dave Tiney ass 1Ag96 Mass 1AD31Z
Name VehEcls License tuber
Weson Inlet wish es, Inc,
Company
7, ion where contents were disposed:
GLSD
Signature of Hauler Dals
signature of Receiving facility(Of otlach facility welpl) Date _
t5lorfm,doc- 11112 System Pumpfng Record -Page 1 of 1