HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1190 SALEM STREET 4/19/2022 Commonwealth of MassachusettsECE�vEra
City/Town of APR 19�022
System Pumping Record
Form 4 TOWN OF NORTH ANDS
M 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 �!{79 n SGc `C m S T
key to move your Address
cursor-do not 40
use the return City/Town State Zip Code
key.
2. System Owner:
r, `
Name
F7J'D
Address(if different from location)
City/Town State Zip Code
307 - /� /6-
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: 006
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes WNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6-GDP/' co 'n 'j 4 I U/1
6. System Pumped By:
Name Vehicle License Number
906aCZf kS .Sep-b'C
Company
7. Location where c ntents were disposed:
�/Cc'Val�
r✓rc0d r�� -
Signature of uler Date
Signature of Receiving Facility(or attach facility receipt) Date
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