HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 7 FULLER MEADOW ROAD 4/3/2023 RECEIVEL
Commonwealth of Massachusetts
City/Town of
System Pumping Record TOWN OF NOR-CH ANDOVEk
Form 4
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.
HOUSE: front ack side rear left 695
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, �•1 1'
6u � P,eGjow
use only the lab T
key to move your Address
cursor-do not
use the return key. City/Town State Zip Code
2. System Owner:
Name
mmn
Address (if different from location)
City/Town . State Zip Code
Telephone Number
B. Pumping Record �t
1. Date of Pumping Date A-A-z 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:
Wof Pelt
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. ..on where contents were disposed:
GLSD
3 I2'�I2�
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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