HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 36 SHANNON LANE 12/5/2022 Commonwealth of Massachusetts RECEIVED
W City/Town of An -ve/l
a = System Pumping Record
Form 4 TOWN OF NORTH ANDUIE1
HEALTH DEPARTM04T
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, / �l
use only the tab 41 r
key to move your Address
cursor-do not MA
use the return Citylrown State Zip Code
key.
2. System Owner:
rab
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
A Z z z
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 pumped:
6. System Pumped By:
Jae
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were d:
20 So. Mill radf MA
nature of Ha er Date
Same day
Signature of Receiving Facility(or attach facility receipt) Date
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