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HomeMy WebLinkAboutSeptic Pumping Slip - 1264 Salem - Septic Pumping Slip - 1264 SALEM STREET 9/18/2024 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 i Y € 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, chack 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 the pumping date in accordance with 310 CM 15.351, _ _ HOUSE: front back sid eat' left' I�ht A. Facility Information BUILDING: front back side rear left right tnlportant:When DECK; under illling out forms 1. System Location: on the computer, use only the lab key to move your Addr ss —� cursor.do not � MA 4 LfS use the relu€n Chy/Towrn key. Slslo Zip Coda 2, System Owner: -a 1 e_ C� �61L Name rrnm ', ACldfoss (If d4fer©nl from tocatwny MA Cllyfrown State - Zip Coda � �• 2I4'. �3 � � Telaphone Nvmbee _ B. Pumping Record 1, gate of Pumping P 9 Date Z 2. Quantity Pumped: 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: Na C-r-J 6. System Pumped By: Dave Tine ass 1AA95E Mass 1AD31Z Name Vehicle Incense N ber Bateson Enterprises, If1c _ Company 7. LaQation where contents were disposed: G L Sl� Signature of Hauler Date Signature of Receiving Facility(or,attach facllily recelpi) Date 15form4.doc- 11112 System Pumping Record Page 1 of 1