HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 WILD ROSE DRIVE 11/19/2020 Commonwealth of Massachusetts
City/Town of ' • �1r2u¢,�
System Pumping Record
Form 4
DEP has provided this form for use by kcal Boards of Health.Other used, but�-e
information must be substantially the same as that provided here. Before using thip fomn, ch k with your
local Board of Health to determine the form they use.The.System Pumping Record'must fled to
the local Board of Health or other approving authority within 14 days from the pumpipiwdu
accordance with 310 CMR 15.351. TOw ctiID
A. Facility Information NOV 19 CO20
ta��when
1. System Location: TOWN OF NORTHANDdVERon the conVular, .
HEALTH DEPARTMENT
key to movl your Address `
do not Y-Nr` �.I.IJU�i MAL Otwo the
key. Ciy/Town state Zlp Gob
2. System Owner.
Name
Addma(M dllbrei tmtn kc")
cityrrown state zip code
i
! TebOww Number
! B. Pumping Record
jav
j 1. Date of Pumping Dab 1 2. Quantity Pumped:
Galions
S. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank E3 Grease Trap
❑ Other(describe):
i 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑l No
5. Observed condition of component pumped:
! 6. System Pumped By:
Nam Vehicle Lk mse Number
c� �x ab
Company
i 7. Location where contents were disposed:
!
sgnalwe of Haub? 0 Date
! Sipnalws of ReceMM Fadkty(or attach hw ft receip) Date
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gyp.11/'Ij Svstem Pwnoirw Record?-Pace 1 of 1
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