HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 111 MARIAN DRIVE 7/15/2020 DECEIVED
Commonwealth of Massachusetts a�� 15 20N
�1 City/Town of _ 1� q n&Vb-
' TOWN
NDOVER
System Pumping Record H ,LTH C)EppR?MENT
Form 4
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 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
filling out forms 1. System Location:
on the computer,
use only the tab I-NQ r Ca ► )
key to move your Address
cursor- not i\ A hd o v e r ', A Q C I�+`--
use the retet not
v `�l J t J
key. City/Town State Zip Code
VQ 2. System Owner:
Pr e C 1-p n 1
Name
term
Address(if different from location)
City/Town State Zip Code
33I - 927 - 13-77
Telephone Number
B. Pumping Record
1. Date of Pumping L0194aO
Date 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): i -------
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
aj,V, ?� ct )
Name Vehicle License Number
Service Pumping 8c pram Co.,Inc,
Company suammspuk
North Reading,MA o1864
7. Location were contents were
III a�
Signature o uler Date
Signature of Receiving Facility(or attach facility receipt) Date
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