HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 261 CARLTON LANE 3/30/2021 j
Commonwealth of Massachusetts RECEIVED
- ;6 City/Town of �h And D 'V MAP 30 Z1071
x System Pumping Record
TOWN OF NORTH AN®OVER
Form 4 wr�!TwpE<PARTMFNT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the Name 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:\^then
filling out forms 1. System Location:
on the only
the tab
�l� 1 /'t„ i , I � � �, r-) e
use only the tab („� 6--(�(�
key to move your Address
cursor-do not t 1 NSA U i i (�
use the return City/Town State Zip Code r
key.
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
9
Telephone Number
B. Pumping Record
1. Date of Pumping Date- 2. Quantity Pumped. Gallons
20�j�
3. Component: ❑ Cesspool(s) 0 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:
Name Vehicle License Number
SeTVICB Pumping$Tha3n Co.,lac.
Company North Reading MA01864
7. Location where contents were disposed:
Lei
LD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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