HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1499 SALEM STREET 8/11/2025 ��
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~ AUG���ste�� ��u������� Record nv« 1 �7�c
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Form 4
DEP has provided this hzrnn for use by |uoe\ Boards of Health. [)therfornns
information must be substantially the sonna as that provided here. Before using this f0rM1.^4Wvvith your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health qr other approving authority within 14 days from the pumping date in
accordance with 318CMR1S.351
HOUSE: front ack side rear left
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
nn the computer,
use only the tab
key»c move your Address
cursor do not MA
use the return
State Zip Code
key. City/Town— —
2. System Owner:
A—ddress(if—different fro—mloc`at—ion)-----
k8A
QtyfTnwn State Zip Code
B. Pumping Record
1. Date ofPumping 2� Ou�ntityPumped� '
Gallons
3. Component Cesspool(s) —",Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present?71
Yes Fl No If yes, was it cleaned? Yes [] No
5. Observed condition ofcomponent pumped:
6. System Pumped By:
D T|n Mass 1AA95E
Name Vehlcle License er
Bateson Enterprises, Inc.
7. Lo ' n where contents were disposed:
t5fonn4dmc-11/12 System Pumping Record^Page 1 of I
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