HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 340 FOREST STREET 1/6/2020 Commonwealth of Massachuse Massachusetts
RECEIVED
r City/Town of 1l ljcl C,VC r- JAN 0 6 2020
System Pu
Form 4 mping Record TOWN OF NORTH ANDOM
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health, Other forms may be used b
Information must be substantially the same as that provided here. Before using this form, check
local Board of Health to determine the form they use. The System Pumping Record must but the
the local Board of Health or other a with your
accordance with 310 CM 15.351,approving authority within 14 days from the pumping date Inubmitted to
A. Facility -Information
Important:When
filling out forms 1, System Location:
on the computer,
use only the tab c C
key to move your Address�� I n r S t`
cursor-do not n 1
use the return i
key. uty/Town
State Zip Code
� 2. System Owner:
K
Name
-�
re r dd e —
Addr (If f
different from location)
City/Town _
State Zip Code —
15. Pumping Record Telephone Number
1. Date of Pumping c
Date 2, Quantity Pumped: I�.� C)C)
3. Component; Gallons
❑ Cesspool(s) [ 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:
Ct► K �' r�, n-F-I rA +rj � C. a SLR Pry
6. System Pumped By:
Name
`ervice Pumping ctt llrain f.;,,�.b Vehicle License Number
5 Haltb.r Park
Company NorthReadiog,KA01864
7. Location where contents were disposed:
Sign l
ature of Hauler - -
Date
51Unnturo of R000iving Facility(or attach fecllity racelpt) Dat�e
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