HomeMy WebLinkAboutSeptic Pumping Slip - 186 CANDLESTICK ROAD 6/6/2018 Commonwealth ofssachusetts
City/Town of NORHANDOVER MASSACHUSETTS 01
System Pumping Record
01� :� �❑ �
Form 4 '` °
i
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Locatio
forms o the
computter,use _
only the tab key Address -
to move your
cursor-do not _..._. _.....__..._v..__ _ —
use the return citylt own State Zip Code
key.
2. System Owner:
Mua-P
Name
" Address(if different from location)
Cityfrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ' �f _---------- 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) lam-Septic Tank ❑ Tight Tank
❑ Other(describe): _ ___.......___.._.
4. Effluent Tee Filter present? es ❑ No If yes,was it cleaned? ' Yes ❑ No
5. Condition of System:
6. System Pumped By:
rC� � ✓f c t
_.. _- _ __...... -.._..._._____.__. _ _....__
Name Vehicle Lrcense Number
i
Company
i
7. Location where contents were disposed:
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms,htm4inspect
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