HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 30 SPRING HILL ROAD 1/2/2024 Commonwealth of Massachusetts
City/Town of Nrkh A,40O�2r
System Pumping Record
Form 4 l wi`' ti tiQL
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, jQ�- 11y ►fj� t }Q
use only the tab
key to move your Address A
cursor-do not A/Qr� �dV� AAA 019 H b
use the return
key. City/Town State Zip Code
2. System Owner:
L-i S Z Y--(-6 rY�
Name
vo SP r► �9 h ► I 1 tLozc(
Address(if different from 1 cation
XJ0 r+11 A-Icf 0 IFS4 S
City/Town State Zip Code
Q-7 8 2 tog
Telephone Number
B. Pumping Record
I l f Z g/�023 1500
1. Date of Pumping Date ,,_,/ 2. Quantity Pumped: Gallons
5a 3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): - -- --- - - ----
4. Effluent Tee Filter presentYes ❑ No If yes, was it -11 cleaned Yes ❑ No
5. Observed
,^(condition of component pumped:
— �U -
6. System Pumped By:
Name Vehicle License Number
-t� >ny , . U' son �lur►►5�n9 s hea i�9
Company
7. Location where ontents were disposed:
G
Signatu of Haur) Date
Signature of Rece Facility(or attac acility receipt) Date
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