HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 94 GRANVILLE LANE 9/3/2020 Ste.\ Commonwealth of Massachusetts RECEIVED
- - City/Town of N AnJww
SEP 0 3 2020
I1 System Pumping Record TOWN OF NORTHANDUVER
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 i. System Location:
forms ontheLn
computer,
r,use y l
only the tab key AddreNoah
to move your wer (vFL45
cursor-do not use the return City/Town State Zip Code
key. 2. System Owner:
� c
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping —Date� L t 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic 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;- A
oxx-0 a C on&LE an
6. System Pumped By:
Rob �yyi-r Y
Name t - Vehicle License Number
Company
7. Location ,where contents were disposed:
(�)C,
Signature of Hauler Date
Signature of Receiving Facility Date
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