HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1174 TURNPIKE STREET 7/6/2022 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record Jul. 062022
Form 4
TC,!VN C.F NORTH ANDEEOVER
DEP has provided this form for use by local Boards of Health. Other fornlsfl� ge 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 11761 '' C
S /
�a!n p i ,
key to move your Address
cursor-do not AlU A n cO Y e r �
use the return City/Town State Zip Code
key.
�1 2. System Owner:
-r�GL(r X (P C r»G any
Name
ream
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping " -�S 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes VfNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pum ed:
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where content7ere
disposed:
U � - //
Signature of FTauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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