HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 40 SALEM STREET 5/13/2026 Town of dover
Noft
Commonwealtf-) of Massachusetts h An
City/Town of
MAY 15 2026
stem Pum
Y pincg. Record
Form 4
Health
DEP has provided this form for use by local Boards of Health. Other forms may be used, ule Department
inforrnation must be substantially the, sarne as that provided here. Before using this form, check with your
local Board of Health to determine the forn-I they use The System Pun-)ping Record must be submitted l(,)
the local Board of Health or other approving authority widhin 14 days from the pumping date In
accordance with 310 CMR 15,35,1
A. Facility Information t�ul�Dwr-,, fron_(._
-rick �l e rear le n In t
nt side rear le fi rip
Important:When DECK: under
piling out corms 1. Systerr) Location.
nr,fIfo cr)mpu(or,
use only tho tat) 0
key to move your Acid oss
cursor -do not Mf
Use the r e l u r n -- _____—�p_.�__. __ __--— --__._ . .. _..._._. __.._ _ __. __..__-- __.._ _._
Ci! !Town
key, Y Stale Zip Code
�l 2. S . tem O ner:
Name
anrn /�k)
Addross (if diHerenl Irom location) — ---
MA
CityrTown sit i —_.
,ore
Teioplione Number
B. Pumping Record
1. Date of Pumping 2. Du@ntity Pumped __._....--
Gallons
3. Component: Cesspooi(s) eptic Tank ❑ Tight Tank [�� Grease Trap
M Other (describe}. -__ ___.._.-. ____.
4. Effluent Tee Filter present? es,If was it cleaned
?- y i___I )Ies fain
5. Observed condition of co 'npo rent purnped.
-(__________-_ -----------
6. System P tmped By:
Dave Tlney __ ---____._. Mass 1AA95E Mass 1AD312
----. - ---- -- --.........
.
Name VEY71CIr r ic,r n.e Ni)rr,ber
"17ateson_Enterprises, inc.
_._.. ------_-._._
Company
7. Location where come e isp0se(1:
GLSQ
Siynaluro of Hauler f a(
P
Signature of Receiving Facitity or afiaCP7 facility recC'ipl) r)a(M �-
t5form4.doc. 11(12 `:wI—n Purnf,)ing Record Page 1 of ��