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HomeMy WebLinkAbout- Septic Pumping Slip - 11/5/2018 Commonwealth of Massachusetts RECEIVED City/Town of System Pumping Record N0V 0 5 ()1fi �� ,•=�Form TOWN OF NORTH ANDOV HEALTH DEPARTMENT 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, check with your j local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in t accordance with 310 CMR 15.351. A. Facility information Important:When Fllting out forms 1. System Location: on the computer, �rr ~� ( use only the tab 6?()..J ,fW L>,-°,J2 f J l/ key to move your Address cursor-do not use the return key. City/Town State Zip Code 2. System Owner: f Name raran . Address(if different from location) Cityfrown " State ( Zip Code _.. Telephone Number B. Pumping Record 1. Cate of Pumping ° ' 2. Quantity Pumped: J ) ©ate Gallons 3. Component: ❑ Cesspool(s) M-�6eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? +'es ❑ No if yes,was it cleaned? tS,Yes ❑ No 5. Observed condition of component pumped: 6. System Pumped By: Name Vehicle License Number Ro company 7. Location where contents were disposed: �r �.-s D Signature of hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc-11/12 System pumping Record-Page 1 of 1 k' -