HomeMy WebLinkAboutSeptic Pumping Slip - 456 Salem St - 11/22/2024 - Septic Pumping Slip - 456 SALEM STREET 11/22/2024 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 CMR 15.351. -------
HOUSE: front ack ide rear left (fl�t
A. Facility Information BUILDING: front 52side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not p-Am t\ �6 -MA
use the return key. City[Town State Zip Code
2. System Owner:
----------
Name
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: 106
DateGallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
0 Other (describe):
4. Effluent Tee Filter present? E] Yes No If yes, was it cleaned? ❑ Yes 0 No
5. Observed condition of component p mped:
6. System Pumped By:
Dave Tlniey Mass 1AA96E ass I A D 3 1Z)
Name Vehicle License Numbe�-
Bateson Enterprises, Inc.
'C�O—m�Pny
7. LQTq ion where contents were disposed:
01
Signature of Hauler Date
Signature of Receiving Facility or attach facility receipt) Date
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