HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 WILD ROSE DRIVE 11/19/2020 (3) Common-wealth of Massachusetts
City/Town of
System Pumping Record
Form 4
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DEP has provided this form for use by local Boards of Health.Other formrrtaye usette,information must be substantially the same as that provided here. Before using
orth your
local Board of Health to determine the form they use.The.System Pumping Rmuitted to
the local Board of Health or other approving authority within 14 days from the accordance with 310 CMR 15.351.
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A. FacilityInformation
NOV 19 ?020
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gft out 1. System Location: TOWN OF NORTHjANDOVER
on Um HEALTH DEPARTMENT
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2. System Owner.
Name
Addren(N dtllereet from location)
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City/Town stab zip code
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Telephone Number
! B. Pumping Record
1. Date of Pumping '�'�f=— 2. Quantity Pumped:
y
g Date ty Gallons
i 3. Component: ❑ cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
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• i 4. Effluent Tee Filter present? ❑ Yes ❑ Plc If yes,was it cleaned? ❑ Yes �No
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5. Observed condition of component pumped:
6. System Pumped By:
Nam w Vehide License Number
Company
7. Location where contents were disposed:
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Sipnatwe of Hauler Dab
i Sig Ahm of ReoeivRq Facility(or attach facility receipt) Date
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tfi MM.doc•11112 Svstem Pumoino Record''i-Pace 1 of 1