HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 116 SHERWOOD DRIVE 2/6/2023 RECEIVED
Commonwealth of Massachusetts
,4 City/Town of FEB 0 6 2023
`( �zV System F'urr�ping Record TOWN OF NORTHANDOVEh
Form 4 HEALTH DEPARTMENT
DEP has provided this form.fdr 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 L°,,%-6-rio(I d Dr
key to move your Address
cursor-'do not �I /
use the return CitylTown IV;; Jri 1/''
key. State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State
WZC
Ide
Telephone Number
B. Pumping Record
1. Date of Pumping �- 7 2. Quantity Pumped: /Yzr
Date Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tan ❑ Tight Tank
9 El Grease Trap
------------------
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No- If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pu ped:
Y >7
6. System Pumped By:
Name Vehicle License Number
1� ) CriC7- l�, � S ('� 4-
Company
7. Location where��ontents were disposed:
Signature of Hauer Date
Signature of Receiving Facility(or attach facility receipt) Date
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