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Home My WebLink About- Septic Pumping Slip - 1475 OSGOOD STREET 12/12/2018 �_ Commonwealth of Massachusetts - City/Town of NORTH AND©VER MA.SSACHUSETTS System Pumping Re Y p g cord Form 4 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 Location: forms on the computer,use only the tab key Address ____ to move your cursor-donok City/Town —.. _._ _._..� _.._._w__.—_-- use the return State Zip Code key. 2, System Owner: Name Address(if different from location) -. ..v. CityfT�.)wn --___. �._.._,_ Skate Zip Code :c, phone Number B. Pumping Record 9, (crate of Pumping 2 Quantity Pumped., Gallons 3. Type of system: ❑ Cesspool(s) Ej<eptic Tank ❑ Tight Tank ❑ Other(describe): r 4. Effluent Tee Filter present? [= Yes ❑ No It yes, was it cleaned? E Yes ❑ No 5. Condditlion of System: 6. System Pumped By: Vehicle License Number _ omp_.__.,any_____ __--. -----, C 7. Location where contents were disposed: Signature of Hauler gate I)ttP://www.mass,gov/dep/water/approvals/t5forms,htr-n#irispect i t5fonn4.doc-06/03 System Pumping Record-Page 1 of 1