HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 61 FOREST STREET 11/16/2021 Commonwealth of Massachusetts RECEIVED
_ City/Town of N• n OVer t
System Pumping Record
Form 4 TOWN 4F NORTH A,NUUVER
tiM` 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 U I Fo r c eA y 47 --
key to move your Address
cursor-do not n o y�.- HA
w 0 I g T
use the return Citylron ^�� State Zip Code
key.
2. System Owner:
COOS t- , SCo-ft
Name
nwn
Address(if different from location)
City/Town State Zip Code
-7'R -7� 0 - �8g0
Telephone Number
B. Pumping Record
1. Date of Pumping I d Date 2. Quantity Pumped: Gallonsl�UD
3. Component: ❑ Cesspool(s) [5( 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:
good _.
6. System Pumped By:
j ay1 i o ►-r.k
Name ,er ice pumping& •,Inc. Vehicle License Number
Company t. NO M K �^"i" �•"° —.
7. Location where contents were disposed:
L
I I � I (al
nature of Hauler/ Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1