HomeMy WebLinkAboutSeptic Pumping Slip - 506 Salem St 9.24.2024 - Septic Pumping Slip - 506 SALEM STREET 9/24/2024 Commonwealth o" MiaSSak-husettS
t City/Town of
f System Pumping Record
,.: Form
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DEP has provided this forM for use u ' . cal Boards ' Heat then for is may be used, but the
information must be substantially the same as th2t provided here. Before using this forty`:., 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 wti; v =o v!vk[l i 1• 351
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A. Facility Information 3 tLD'N , rout back side rear right
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Address (if different from location)
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I eiephone Number
B. Pumping Record �-
Date of Pumping 2 antity Pumped: Gallons
Date
3 Component: esspooi;sj �oWttink ❑ Tight Tank [] Grease Trap
Other (describe):
4. Effluent Tee Filter present? 0 Yes ' �c f yes, as if cleaned? � Yes �i No
5. Observed condition of co„Donent pu:nnne
& System Pumped By
cave T;net. Mass 1AA95E Mass 1AD3^7
Name vehicle License Number
B2teson Cnfer crises, MC
Company
.. L ccation where contents were disposed'
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Sienature of Hauler . — Dae
Signature of Risceiving Facility(or attach facility receipt) Date
t5form4.doc` 11112 System Pumping Record- Page 1 of i