HomeMy WebLinkAboutSeptic Pumping Slip - 1116 Salem St - 11/13/24 - Septic Pumping Slip - 1116 SALEM STREET 11/13/2024 t Commonwealth of Massachusetts
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System Pumping Record
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`V Form 4
DEP has provided this form for use by local Boards of V-iealth, Other 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 Systern Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from *,he purnping date in
accordance with 310 C MR 15.351, — --.--
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Telephone Number
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B, Pumping Record __/.._.
1. Date of Grumping /_/ __._._ -..__.. . ------
Date G 6n 811s
3. Cornponent: �_] Cesspool(s) Z,,�5_eptic rank ❑ Tight Tank ❑ Grease Trap
I__1 Other (describe)
4. Effluent Tee Filter present? �_.) ti'es o P yes, was it cleaned? Yes No
5. Observed condi(Iori of c,)rn ponent pttrnped
6. System Pumped By.
(Dave 1!nPY___,___ -_ Mass 1AA95E Mass 1AD31Z
Name Vehicle Lice,nse, Number
Batesorn Enters)rises, lfic
c n,pany
7 Location where contents were disposed:
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Sign to e of
Date
Signature of Receiving racllity (or a(lach facihy rccipt) ['fate
t5lorrN.doc- '11112 Systern Purnping Recorc' - page 1 of 1