HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 151 SANDRA LANE 11/23/2020 Commonwealth of Massachusetts
City/Town of J i RECEIViD '
System Pumping Record ;
Form 4
Nov 23-26..-
it TOWN OF NORTH^-
DEP has provided this form for use by local Boards of Health.other •A1sed, 4b=bff
inforrnetion must be substantially the same as that provided hero. Before using this with your
local Board of Health to detartnine the foam they use.The System Pumping Record must itted to
the toed Board of Health or other approvkfg authority within 14 days from the date
accordance with 310 CMR 16.361. ,
A. Facility Information
sko ad 1. System location:
my to your Ad*n +
MY. CW own slab
Zip Cods
2. system Owner: ,
Addr.as(N dWarad ban Mca m)
1
CWTown Sfale �P code
TelerNrorrs Nrarrlrer
B. Pumping Record
1. Dale of Pumping 2. Quantity Pumped: Galom
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3• Component: ❑ Cesspool(e) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it deegied� ❑ Yes
. ❑ No
i S. Ob"condition of component pumped:
1 0. System Pumped By:
�-Jci ri s fir.`;aLo
V*Mde License Numbs r
con " f
7. Location where contents were disposed:
1
Slprw*m or Hmdw Dafs
S*w m of Receirkrp Feaft(or Mach(soft n we") Dab
I
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f6rorwAAicw 11112 SvMem Pumokw Record-Pace 1 or 1