HomeMy WebLinkAbout- Septic Pumping Slip - 1077 OSGOOD STREET 6/7/2022 Commonwealth of Massachusetts �ECE'vED
v City/Town of
System Pumping Record SUN O'12022
Form 4 TOWN OF NORTH WDOVER
'�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, /O - 0 � L
use only the tab ^l
key to move your Address
cursor-do not MA
use the return City/Town State Zip Code
key.
2. System Owner: 1 ff r�
Name ----- — — —
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 3( z 2. Quantity Pumped: Gail6 ns
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): _-
4. Effluent Tee Filter present? ❑ Yes 9 No If yes, was it cleaned? ❑ Yes Ef No
5. Observed condition of component pu py d:
Q�St
6. System Pumped By:
Name I Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill S , Bradford, M
ature of Hauler Date
Same day
Signature of Receiving Facility(or attach facility receipt) Date
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