HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1001 JOHNSON STREET 6/4/2020 - Commonwealth of M ------ --__- _
assachusetts
%I City/Town of RECEIVED
Sy-gt8m Pumping Record JUN 0 4 2020
Form 4
DEP has provided this form for use b to TOWN OFNORTHANDUvER
information must be substantially the same as that provided here. HEALTH DEPARTMENT
Y cal Boards of Health. Other forms maybe used, but the
local Board of Health to determine the farm they use. The System Pumping Record the local Board of Health or other approving Before using this form, check with your
pp g authority. must be submitted to
A. Facility Info
rmationImportant:
When filling out' 1. System Location:
forms on the _ !
computer,use
only the tab key Address ~
to move,your
cursor-do not
use the return City/Town—Town
ity/Town —G
key. State
Zo2- System Owner; 7-Jp Code
iz Name
Qfl—
Address(if different from location
,V/Town
State Zip Code
S 7
i eleph 3ne Number
�. �umpia�� �ec��°� •
1. Date of Pumping - J ' 02 l- -2
Date 2. Quantity Pumped:
3. Type of system: ❑ �aiions Cesspoo!(s) � Septic Tank El Tight Tank
El Other(describe):
4. Effluent Tee Filter present? ❑ Yes No
If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: ti
6. System Pumped By:
Name
Company Vehicle License Number
" Ze IDS SC rc
7. Location where contents were disposed:
LS
Signature of Hauler
Date
t5farm4.doc•06/03
System Pumping Record•Page 1 of 1
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