HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 74 FULLER ROAD 7/27/2020 Commonwealth of Massachusetts RECEIVED
w y City/Town of lWeve,r JUL0
System Pumping Record
TOWN OF NORTH ANUOVER
Form 4 HE4LTH 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 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, �aer- vd,use only the tab
key to move your Address _.
cursor-do not
use the return MA
key. City/Town State ----
Zip Code
2. System Owner:
Name — --- - ------ -
Address(if different from location) -- - --
City/Town State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping oat-e 2, Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) tfJ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 2-No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of c mponent pumped:
S
6. ,System Pumped
Name Vehicle License Number
Stewart's Septic 58 So Kimball St., Bradford MA
Company
7. Location where contents were disposed:
20 S ill St., Bradford,
::�- 7 - 0
Signature of Hauer Date
Signature of Receiving Facility(or attach facility receipt) Date
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