HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 557 BOXFORD STREET 9/8/2020 Commonwealth of Massachusetts RECEIVED
City/Town of _ A ncd OVU— SEP o S 70?t7
System Pumping Record TOWN 0FNUR1hANuUVER
— % 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 577 G-)
key to move your Address
cursor-do not A
use the return
key. City/Town State
Zip Code
VQ 2. System Owner:
_ M �trCc.. J us
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dat9- �tJ 2. Quantity Pumped: ' GD G
Gallons
3. Component: ❑ 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. Observed condition of component pumped:
6. System Pumped By:
�1 11 �
Name
Vehicle License Number
Service,Pumptnlg do Drain Co.,Inc.
Company Pak
North Reading,MA01864
7. Location where crtsMere Isposed:
G
Signature of Hauler �21? I
Date
Signature of Receiving Facility(or attach facility receipt) Date
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