HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1264 SALEM STREET 4/21/2026 s rtl�� over
C�ammar�wealth of Mass��cl�usett
City/Town of _ A
2626
v SystemPear
-nping—Rc arch
Form 4 Health n
DEP has provided this forrn for use by local Boards of i-ieajth. Other forms may be rased, but the
information must be substantially the sarne as that provided here. Before using this form, check wilt") your
local Board of Health to determine the form They use The Systen-f Purnping Record must be submitted to
the local Board of Health or other approving aulhori(y within I days from the purnping date in
accordance with 310 CMR 15.351 ---..--------__ ---__ -_ _
c_.__.__ ._y t-i C)US E front back s i the r e a r 10
f
A. Fgcilit Inforrnation BUIt.DIN Ci front bar} si(e fear Icft
m)ortanC when DECK: under
011hrl out(orms 1, Cystern (_-o-c-a-��.ar_T
of)the conpnlot, � C_�.
/��qo 1e Ie>
kc,,y to rnovr;�yo,tn
cursor e do rrol
�jtr+ the r-elum —._.
Cily�i"own __—_ _.__
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Key, �lalo Zip Code
2. r ,tern Owner:
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IIIL-11-1
IL
QN
Acldrrss (I(UiHereni (turn Icx:alion) -- -- --
--------- MA
--- -—- _
ciryrrow -
n
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31a1ea. Zip Colt;
elephunc Nurnbr_r
_.._.
B. Pumping Record
- __ _..----------._-__.
1. Date of Porn in
p 9 DaIe -.--------- 2. Quantify Pumped - --... -
G Ions
3. Companent: [] Gcsspaol(< ) aptic InS< [_�_J Tight Tank IJ Grease Trap
Other (describe:).
4. Effluent Tee Filter present? [.] Yes _ No f yes, was it cleaned? F] Yes ❑ No
u. Observed condition of cornpone t
r stern Pt,mped By
Dave -rine_y __ _ ____ Bass 1AA95E Mass 1AD317_
�n1e vehlGln License Nurn-Fr,
t "son Fnferprises_ inc.
Corhpir)y _.
7. L Lion wf e ;Wc is we le disposco
Slgnaluro of Hauler Datr
nature of flecaawing Facility (car allach (aoih[y feccmpl}
15forrn4 doc, '1 1112 ryslern Purnping Record fir ue 1 0(