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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 520 SHARPNERS POND ROAD 7/7/2020 Commonwealth of Massachusetts C►ty/Town of %IRECEIVED 'y-9tem PUMPQng Recorrc9 JUG p Form 4 Z 202U PEP has Provided this form foruse b (o TOWN©FNORTH information must be substantially the same as that rovid HEALTH DEpA ed,but R Y cal Boards of Health. Other forms maybe used coca! Board of Health u determine the form they use.The System Pumping but the the local Board a Health et otherthe form authority.e ed here. Pumps using this form P 9 Record ' check with your approving must be submitted to A Facility inforrmatl®aa Important: When filling out' 1_ item 4�Fation: forms on the computer,use '"v .only the tab key Address `\` '' j� c to MOVP—YOUF �p cursor=do-not use the return CIty/Town A key. 2- System O State Y caner: Zip Code n3 ca:! Name Address ifd' ( 'fferentfrom location) CitylTouvn State ZIP Cad Telephone Number t. Date of Pumping � ��� Date ' 2. Quantity Pumped; /,�1� 3. Type of system: Gallons ❑ Cesspool(s) �j Septic Tank ❑ Tight Tank ❑ Other(describe): ?• Effluent Tee Filter resent?P ❑ Yesof No If yes,was it cleaned? 5. Condition of System: ❑ Yes ❑ No 6. System Pumped By; ,- Name &!7 rr <, Z� ��S Vehicle License Number Company S �7"r C 7. Location where contents were disposed: �S D Signature of Ha er Date t5form4.doc-06103 System Pumping Record.Page 1 of 1 MM