HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 237 CARLTON LANE 10/16/2019 Commonwealth of Massachusetts Rc ®
City/Town of_LL_Lq v�cl Cwe,r OCT 16 2019
System Pumping Record
' Form 4 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
local Board of Health to determine the form the the local Board of Health or other approving authority within 14 da s fromUse.The System heRecord Pumping date Inubmittedoto
accordance with 310 CMR 15,351.
A. Facility Information
Important;When
filling out forms 1. System Location:
on the computer,
use only the tab �� �� �� t
key to move your Address
Ln
cursor-do not
use the return ��
key. City)town 1 1 SC I,�S State tip Code
Q
2. System Owner:
Name
Addr Ifsse different from location)
City/Town _
State Zip Coda
Telephone Number J`1 7 _ 7 7�F
B. Pumping Record
1. Date of Pumping - �_
Date 2. Quantity Pumped: r
3. Component:
Gallons
❑ Cesspool(s) Q Septic Tank ❑ Tight Tank
❑ Grease Trap
❑ Other(describe): _
4. Effluent Tee Filter present? ❑ Yes ❑ No
If yes, was It cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
J
6. System Pumped By:
i9 . ,"" i--N a I O
Name ------ 0 + —7
Scrvicc pure it &Drain;-. Vehicle License Number
p �8
Company
North peleirg,%f f
7. Location where contents were disposed:
L�
Signatu of Hauler /n
Date r -
5lgnaturo of Receiving Facility(or attach feoillty receipt) Date
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