HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 48 WINDSOR LANE 12/6/2021 Commonwealth of Massachusetts
W City/Town of
System Pumping Record ) C G ?021
M , Form 4 Tn��N OF NORTHn NuovER
RENT
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 41 LnJ OCA0 C n
key to move your Address
cursor- not
use the return
urn key. City/Town �— State Zip Code
2. System Owner:
s-I0nec � C' �
Name
roam
Address(if different from location)
City/Town State Zip Code
y 9 ?3 - -73S3
Telephone Number
B. Pumping Record
1. Date of Pumping Date // _ J 2. Quantity Pumped: Gallo/ �� 00
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 compo nt pumped:
C I Ud e)i
6. System Pumped By:
Name Vehicle License Number
130(-�C7c � S
Company
7. Location where cont nts were disposed:
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
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