HomeMy WebLinkAboutSeptic Pumping Slip - 444 Salem St 9.9.2024 - Septic Pumping Slip - 444 SALEM STREET 9/9/2024 Commonwealth of Massachusetts
w City/Town of
System Pumping Record
Form 4
;DEP has provided this form for use by local Boards of Health. Qther 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 the pumping date in
accordance with 315 CMR 15.351. -
HCUSE: fron<0 side rear le righf`
A. Facility Information au!!DING: front back side rear left right
important:when DECK: under
fliifng out forms t. System Location:
on the computer, (—t rf
use only the taw
S-1 lelv-1 —) 4—
Kevto mope your Address
cursor-do net u, Al Llt-- MA
key.y the return CityfTown State Zip Code
Ur12. System Owner.
�f 1) 1
l Name
ream
Address (if different from location) p,
V�i A
CltyrT"own State Zip Code
6
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:Gat
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank g ❑ Grease Trap
Other (describe,:
4, Effluent Tee Filter present? n Yes No if ves, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Cave Tiney Mass 1AA95E Mass
Name Vehicle �lcense N r
Bateson Enterprises, inc.
Company
7, on where contents were disposed:
G2D
Signature of Hauler Date
Signature of Receiving Facility(or a ach facility receipt) Gate
t5form4.doc• 1112 System Pumping Record• Page 1 of 1