HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 66 PENNI LANE 1/14/2021 Commonwealth of Massachusetts 14 '���
--rs City/Town of oFNOR�NAN�vER
System Purnping (Record i0���"°�pP�� ; N1
Form 4
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 Re,::ord must be submitted to
the local Board of Health or other approving authority within 14 days from the primping date in
accordance with 310 CMR 15.351.
A. Facility Informaitiion
Important:When
filling out forms 1. SyStEfm Location.
on tia computer,
use(nly*he tab _ _-__ ----
key t.)move your Address
cur cr-do not �, And ayP-k- MA U li�115
use the return City/Town State Zip Code
key
` 2. System Owner:
P _ Pau ti t
Name
Address(if different from location)
City/Town - --- --- State Zip Code
q 9f '-X3 5- `E7 (`+---
Telephone Number
B. Purnping Recordl
1. Date of Pumping Da1e 2. Quantity Pumped: talons
3. Component: ❑ Cesspool(s) [9 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 ccmponent pumped:
6. System Pumped By:
14
Name Vehicle License Number
Servloe pumping&Dndn Co.,Inc,
Company NoctLReeding,MA01864
7. Location where con 4`'r�r
Cs�n`i re IsposecT-.
���Signature of Hauler Date �-t—
Signature of Receiving Facility(or attach facility receipt) Date
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