HomeMy WebLinkAboutSeptic Pumping Slip - 1550 Salem St - 11/26/2024 - Septic Pumping Slip - 1550 SALEM STREET 11/26/2024 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
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, 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 310 CIVIR 15.351.
HOUSE: ( front back side rear left righ
A. Facility Information BUILDING: front back side rear left right
Important;When DECK: under
filling out forms 1. System Location,
on the computer,
use only the tab
key to move your Address
cursor-do not MA ifs
use the return
key. City/Town State Zip Code
2. System Owner:
Name
MA
ityrrown stet s� 43 Zip Code
-Telephone Number
B. Pumping Record
1, Date of Pumping 2. Quantity Pumped.
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank 7 Tight Tank 7 Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? M Yes 7 No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tlney Mass 1AA95E ss 1 AD-3-t?
Name Vehicle License Numbdr,.��
Bateson Enterprises, Inc.
CO-M—piny`--
7. tion where contents were disposed:
GLS
U24 �Signature of Hauler Date
-Signature of Receiving-Facility(ar attach facility receipt) Date
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