HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 115 CRICKET LANE 7/7/2020 Gammonwealth of MassachusettsR ------___ ------_ ..
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ECEIVED
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�Ysteyn PumPing Record o � 2o2v
Form 4 TOWN OF NORTRANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms May be
information must be substantially the same as that provided here. Before Usingthis
local Board of Health to determine the form they use.The System Pumping R y used, but the
the local Board e Health et otherthe form
s form, check with your
approving authority. 9 Record must be submitted to
�o Facility
Important.
When fining out-
forms 1. System ion:
on the
computer,use '
.only the tab key Address
to move,Your
cursor=do.not
use the return cV"-'own
key, state
t�Q 2- System Owner: ZIP Code
Name ' ri
r` Address(if different from location
Ci 'Town
State Zip Code
i eiephone Number
1. Date of Pumping r X - __aO
Date 2. Quantity Pumped: G
3. Type of system: canons
❑ Cesspool(s) Xseptic Tank
❑ Tight Tank
❑ Other(describe):
4• Effluent Tee Filter resent?p ❑ Yes No If yes, was it cleaned?
❑ Yes ❑ No
5. Condition of system: ti
6. System Pumped By:
Name
vehicle License Number
r'^ r Ze
company r
7. Location where contents were disposed:
—
Signature of Hauler
Date
0nrm4.doc^06/03
System Pumping Record Page 1 of 1
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