HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 125 WINDKIST FARM ROAD 11/19/2020 Commonwealth of Massachusetts RECEIVED
o City/Town of _ �C)o v
_- System Pumping Record NOV 19 2020
Form 4
TOWN OF NORTH W)OVER
DEP has provided this form for use b local Boards of Health. Other for FALTH DEPARTMENT
Y rr 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, I
use only the tab ntk k 1 S i— F,.r m
key to move your Address
cursor- not ►V A nC�oyr �
use the retet not
key. Cityrrown State
Zip Code
VQ 2. System Owner:
(j.-) +mod Ki S t- 7E6 u cs4-r C t ►�
Name
Address(if different from location)
City/Town State
Zip Code
°I 7
Telephone Number
B. Pumping Record
1. Date of Pumping I Ddle l a'�C' 2. Quantity Pumped: I sTjo
Gallons
3. Component: ❑ Cesspool(s) [gj 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:
AncA rz>&) 4c)I 10. d ifa I
Name Service vehicle License Number
�P�S 6t Drain Co.,Inc.
5 Hallberg Pwk
Company
7. Location where contents were disposed:
S auler + f !'�� �tJ��✓
Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12
System Pumping Record•Page 1 of 1