HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1001 JOHNSON STREET 7/8/2019 RECEIV Em D
�-,L\ Commonwealth of Massachusetts
Gity/Town of
System Pumping Record
TOWN OF NOR"il H ANL)OVER
Form 4 DEPAJ MEW
DEP has provided this'form for use by local Boards lth. Other forms may be used, but the
Information must be substanfially the same as that provided here,. Before using this form, check with your
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
accordance'with 310 CMR 15.351.
A. Facility Information
Important:When
f c"
fill(ng out ms Syis em L forio ationl-
on the computer,,
yse only the tab
key to rnove your Address
oursor
/Vd
le
use!the return
Cltyfrown State Zip Code
key.
2. System Owner.,
el S,0 V
Name
Address(if different from location)
City/Town State Zip Code
7d
Telephone Number
R. Pumping Record
6 z 0
1 Qu it,. Date of Pum 2. an ping Date ty Pumped: Gallons
3. Component Clesspool(s),-- eptic Tank E] Tight Tank F.] Grease Trap
Other(describe):
4. Effluent Tee Filter present? E] 'Yes � o If Yes, was"it cl ned? El Yes [:1 No
5. Observed condition of component pumped:
6. System Pumped By:
Name Vehicle License Number
Company T
7. Location where contents,were d1sposed':
Signature of Ratiler Date
Signature of Receiving Facility(or affach facility receipt) Date
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