HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 254 LACY STREET 5/19/2021 Commonwealth of Massachusetts RECEIVED
City/Town of 1:-'(�pVe.r- MAY 19 2021
System Pumping Record TOWN OF NORTH AAN
Form 4 HEALTHDEPARTMENT
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 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,
use only the tab
key to move your Address
cursor-do not �� I� —'—"--
use the return A
key. City/Town
state Z1p Code
VQ 2. System Owner:
Name
Fnk
Address(if different from location)
City/Town State
Zip Code
It 17 - (Xte - -?v IC
Telephone Number
B. Pumping Record
1. Date of Pumping `
Date�
)- 2• Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Q! 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;
InCL 1 J J V � !
Nant• Pumping Vehicle License Number
6%1)ratn Co.,Inc.
S et Rftrk
Company North Rt 6 ft MA 01864
7. Location where contents were disposed:
( LIS ip
Signature of Kauler Date
Signature of Receiving Facility(or attach fealty receipt) Date