HomeMy WebLinkAboutSeptic tank - Septic Pumping Slip - 115 CRICKET LANE 8/4/2021 Commonwealth of Massachusetts
,64 City/Town of RECEIVED
I System Pumping Record AUG 0 4 ?0' 1
Form 4 1
TOWN OF N0RT8AA[ VFp
DEP has provided this form for use by local Boards of Health. Other fora j� h mot,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. SgS`fem Location:
on the computer,
use only the tab // C ,` C K P J
key to move your Address
cursor= et t no
use the return Cit frown ✓1 �'1
key. y State Zip Code
2. System Owner:
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Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 7 7 I 2. Quantity Pumped: l S
Date 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 corn nent pumped:
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6. System Pumped By:
Name Vehicle License Number
SOcc"Cze k S
Company
7. Location where contents were disposed:
LSD
6 c'o <-V
Signature of-Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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