HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1337 SALEM STREET 6/4/2020 commonwealth of Mass
City/Town of Massachusetts RECEIVED
F System PUMP ng Decor
JUN 0 a. 2020
Form 4
DEP ha TO WN OF NORTH ANWVER
HEALTH DEPARTMENT
s 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 f
local Board of Health to determine the form they use. The System Pumping Record the local Board of Health or other a rovin form, be submitted
with your
pp g authority. must be submitted to
A. �acaiQ�y Bn�®�ma�6®�a
Important:
When filling out' 1. &yStem Wcattan:
forms on the yj
computer,use
-only the tab key Address
to moveyouF
cursor-do not �U.
use the return Cltylibwn 1/e"r
key.
2• System Owner: state Zip Code
lbro
vV2 Name
QR1
Address(if different location
Ct ,Town
State ZIP Code
Telephone Number ��
�. Pumping sec®�-e8
1• Date of Pumping
Date 2. Quantity Pumped: UGC}
❑ Other(describe):❑
3• Type of system: Gallons Cesspool(s) ,Septic Tank
❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned?
❑ yes ❑ No
5. Condition of System: ti
6. System Pumped By:
Name
Vehicle License Number
Company
7. Location where contents were disposed:
LS D
signature of auier
Date
t5form4.doc^06103
System Pumping Record•Page 1 of 1
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