HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 31 JAY ROAD 9/8/2020 Commonwealth of Massachusetts RECEIVED
City/Town of _ t\ _� �Gj DV�y SEP 0 8 1p`113
�A __ _ System Pumping Record vER
TOWN OF NORTH ANDO
- ` Form 4 HEALTH DEPARTMENT
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 forms 1. System Location:
on the computer,
use only the tab Rd
key to move your Address
cursor-do not ( Y) v l ( (�
use the return -----__1�L._ fl_ ("' 0
key. City/Town State Zip Code
VAQ 2. System Owner:
Ltd_h r'�C. 5 U_Zan 0Name
ret m
Address(if different from location)
City/Town State Zip Code
o -- o�
Telephone Number
B. Pumping Record
1. Date of Pumping Date o7 - 2. Quantity Pumped: - 0 —
Gallons
3. Component: ❑ Cesspool(s) j Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? [ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Name Mtng
5 Hattberg Park --- Vehicle License Number
—ilorthRe�rtlin�MAQi�6+t
Company
7. Location where contents were disposed:
gla � 1 .2C)
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date -
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