HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 263 RALEIGH TAVERN LANE 11/19/2020 Commonwealth of Massachusetts RECEIVED
City/Town of Nov
A TOWN OF NORTH ANDUVFR
System Pumping Record
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, 1 /'
use only the tab — —�' 23 RW t ( h Tc"V h L-,C>-
key to move your Address
cursor- not / L�n f\► i --�`
use the return
urn /�! /` I
key. City/Town State Zip Code
2. System Owner:
r
Name
rC,✓n
Address(if different from location)
City/Town State
Zip Code
Telephone Number ---
B. Pumping Record
1. Date of Pumping Date - +f -_ 2. quantity Pumped: ----
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:
ao— - -----
6. System Pumped By:
Name -- .-�—- - --- —
Vehicle License Number
- Service Pumping&Drain Co.,Inc.
Company -
North Reading,MA 01864
7. Location where confe�it tgl *&s Fd:
Si
Signature of +C1 - ��---Date -----
Signature of Receiving Facility(or attach facility receipt) Date -
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