HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 BRIDGES LANE 8/13/2020 - commonwealth of Mass RECEIVED
�.. city/Town o, acht�se �
.,
AUG 13•Z-U?d
F System PUMPI n g Record' TOWN OF NORTHANDOVER
• - ®rfn 4 :HEALTH.D.EPARTMENT
DEP has provided this form fot-use by local Boards of Health. Other f
information must be substantially the same as that provided here. Before usin
local Board of Health to determine the form they use.The System Pumping arms maybe used, but the
the local Board of Health or other approving g thin form, check with your
pp g authority. Record must be submitted to
A. Facility lnforrmaatio d
Important:When mina out_ 1__ tarn i;°�ation:forms on the
computer,use -
.only the tab key Address �` S
to move_.90uF )
cursor=do.hot
use the return CitylTown - - c) 1i
key. State
2- System Owner; Zip Code
vvz Name TC,
Addrose(if dffrerentfrom location
City/Town _ -
state
Zip Code
Telephone Number
Lib tl 1Y9�1.j•YYY� YR40 Vm®��1 -
i_ Date of Pumping 7- �Q
Date 2. Quantity Pumped;
3- Type of system: ❑ Gallons Cesspool(s)
Other(describe): Septic Tank
❑ Tight Tank
❑ .
?. Effluent Tee Filter resent?p ❑ Yes 7f No if yes, was it cleaned?
5, r nnHifinn ..r ❑ Ys5 ❑ No
.. � I Ul oystem: ti
6. System Pumped By:
Name
Company 'I 541 s
Vehicle License Number
r� t^ Ze 1c
7. location where contents were disposed:
Z-S�
Signature of Hauler Date
t5form4.doc-06/03
System Pumping Record.Page-I of I
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