HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 790 FOREST STREET 9/3/2020 S,-\ Commonwealth of Massachusetts RECEIV
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City/Town of NQ t(�} And O v eY' SEP
.�. System Pumping Record IoWt4()FN0RTHANUUVER
L ,ram Form 4 HEALTH DEPARTMENT
REP 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 p the q e���
computer,use t only the tab key Address {,,
to move your Nof1� �
cursor- not
use the return Cityfrown 1— StateY Zip Code
key. 2. System Owner:
t&111 IC t_e�
Name
Address(if different from location)
Cityfrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date��L 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: f 1.
4ion
6. System Pumped By:
Name1 vehicle License Number
AV C E
Company
7. Location where contents were disposed:
�r�1 `l
Ns
Signature of Hauler Date
Signature of Receiving Facility Date
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