HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 WILLOW RIDGE ROAD 5/11/2021 Commonwealth of Massachusetts RECEIVED
City/Town of MpY 1 1 2021
System Pumping Record
Form 4 TOw%OF NORTH ANoOvER
HEALTH DEPARTMENT
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 s ji. I I ( r [�
key to move your Address
cursor- not �� LA
use the return
yurn Cit /Town 7
key. State Zip Code
2. System Owner:
Name
Bern
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date a 7- �r 2. Quantity Pumped: 1 OOJ
Gallons
3. Component: ❑ Cesspool(s) 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:
rr)LIC�
6. System Pumped By:
Name Vehicle License Number
& r6'f Z e-lT S
Company
7. Location where contents were disposed:
Signature o�uler Date
Signature of Receiving Facility(or attach facility receipt) Date
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