HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1749 SALEM STREET 5/5/2026 of
�a Commonwealth of Massachusetts �� �n1 over
City Town of
- -__._----- MAY 20
S stern P 26
y Pumping Pec:orci
Form 4
`Ae r It epartm n
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, cheek with yoi.ir
local Board of Health to determine the form Chey use, The System Pumping Record must be submittecj (o
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
-- H0USE, rant back side rea eft right
A. Facility Information BtjILF)ING: front back side fear rnt,h,t
important: WI'ien DUK: under
(filing out forrns 1. System Location,
on
ke(I to move`Ito' Add a
use only the tab
Y your mess __---
cursor-do nor MA
u e (he return
GIty own --
kr�y. Slate Zip Code -
2. System Owner.
Q4-- A-
it
M M
Name - -- _- ---.__----------------
Irlrrl, r
Address (if different frorn location)
�� ___�_----_----_._. MA
City(1 Uwn - _. _-_--
,dale Zip Code _..
eler>hone hJ,mber
e. Pumping Record
1. Date of Pumping "'"�
p 9 __.._ __ ___.__. 7,. Quantity Pum rid. e
C7ala y Gallons
1Component: C] Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease 1"rap
Other, (describe) --- ----
4• Effluent Tee Filter present? [] Yes (- No If yes, was it cleaned? [_] Yes ❑ No
5. Observed condition of cornponent purnped
6. System Pumped By:
Dave 1'Iney-- -- ------- ..__--- ---_ _ .__._ Ma Mass 1 AD31Z
— ---— --_ _------------
Name \/ohlCln l_icentie urr'7bCr
eateson Enterprises, Inc._
Comp,iny
7.U
where contents were disposal
slgnalt ro off filer D<{(c
-- -- - ---
Signalure of Receiving Facility (or a(iach facility receipt)
t5forrnd.doc- 11/12
System f7urnping Record Page 1 of t