HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 602 BOXFORD STREET 9/3/2020 \ Commonwealth of Massachusetts RECEIVED
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System Pumping Record TOWN OF NORTHANDOVER
` I y p. g HEALTH DEPARTMENT
/ 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 1. System Location:
forms the r O� UX-RJ d
computer,
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only the tab key Address �/ y� ^ (� {� /� , `
c move your No l n r" '(�t yef /`} 01� '5
cursor-do not —�—�1-�
use the return CityfTown state Zip Code
key. 2. System Owner:
ra
Name
Address(if different from location)
CityfTown State Zip Cade
Telephone Number
B. Pumping Record T�
1. Date of Pumping Date 2. Quantity Pumped: `Gall0 v
ons
3. Type of system: ❑ Cesspool(s) Aseptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
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6. System Pumped B
,_ �3 raayn
Name J1
A)\yn FV-,yam�- Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility Date
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