HomeMy WebLinkAboutSeptic Pumping Slip 12-16-2024 - Septic Pumping Slip - 518 SALEM STREET 12/16/2024 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 lz ck side rear 9 right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, 45-L t use only the tab C!
key to move your Address
cursor-do not AJ A MA
use the return
key. C1ty[ToWh State Zip Code
2. System Owner:
Address'res'—(if—different from location)
...... _MA
CityrTown State Zip Code
V'7
I_')0
-telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: —ce
Date Gallons
3. Component: 7 Cesspool(s) Septic Tank 7 Tight Tank 7 Grease Trap
Fj Other(describe): ----------
4. Effluent Tee Filter present? Fj Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component 7umped:
6. System Pumped By:
_Pave Mass 1AA95E fOass 1AD31
Name Vehicle License Numbel.'��
Bateson Enterprises, inc.
Company
7. 4:og ion where contents were disposed:
GLSD
Signature toLa u I e_rr Date
Signature�ofRec4i_'iv_1ng1Facir4(or attach Date
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