HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 43 WINTERGREEN DRIVE 10/7/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of OCT 0 7 2022
System Pumping Record TOWN OF NORTHANDOVEf
HEALTH DEPARTMENT
Form 4
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. ---
HOUSE: front back sidCLear ft ig�
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. Sys 2r71 LO tion:
on the computer, �
use only the tab
key to move your A213AR1-171
cursor-do not
use the return ty/Town State Zip Code
key.
2. System Owner:
tab / A
—e
ierwn
Address (if different from location)
City/Town State Zip Code
ct5 - Sqg�
Telephone Number
B. Pumping Record
Gam/
1. Date of Pumping Date 2. Quantity Pumped: Gallons
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 component p m���
C
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
GLSD
IX 4
Signature o er Date
Signature of Receiving Facility(or attach facility receipt) Date
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