HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 125 WINDKIST FARM ROAD 5/19/2021 16N- Commonwealth of Massachusetts
City/Town of .AyN C�Cge V' RECEIVED
System Pumping Record MAY 19 ?0
Form 4
TOWN OF NORTH AN>UVER
rr-pTVENT
DEP has provided this form for use by local Boards of Health. Other forms may Vj�ALTH be used butthe
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 Addrea 1 1C
cursor- not f j L\ ,
use the return r 41 1�'1 A ,A
key. City/Town stab ZIP
t
2. System owner ZIP Code
W 1 Y' d K i S D f 1 t' 1.--j yl (`t'Y7 3-r"Nwm
�---
Address t0 different from location)
City/Town State
7 ZIP
Telephone Number
B. Pumping Record �
1. Date of Pumping 1110121 — 2. Quantity Pumped:Dift—
f f
(3allons
3. Component: ❑ Cesspoa(s) 0,1Sept1c 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:
Anclt,p >/_)
Name ico Vehicre Dense Number
Pumping 8t Drain A;q.,InC.
S Hallberg Park
Company dontb Reading,MA 01864
7. Location where contents were disposed:
S n oats i
Signature of Receiving Facility(or ottaoh fponity reoorpt) Date