HomeMy WebLinkAboutSeptic Pumping Slip - 9/5/2024 - Septic Pumping Slip - 75 SHERWOOD DRIVE 9/5/2024 4 Commonwealth of Massachusetts Town Of NorthAndover
M City/Town of c
System Pumping Record .. 4 202
Form 4
DEP has provided this farm for use by local Boards of Health.Other forms
information must be substantially the same as that provided here. Before using this for ,,c 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 -_ _
key to move your Address _
cursor-do not LrLi
"
use the return _ -__ _..__.. ___ _._.
key. City/Town State Zip Code
2. System Owner:
m
Name
Address(if different from location)
City/Town State Zip Code
.. _ _. ......
Telephone Number
B. Pumping Record
1. Date of Pumping Da te Gallon
_...._ __.._ 2. Quantity Pumped: .
s ....
�
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 condi 'on of component pumped
6. S stem Pumped By _..
ame r Vehicle License Number
Company
7. Location w re ontents were disposed:
��.
Sig, u ler Date
_._ _..._ ... .._._ -._. _.._
Signature eiving Facility(or,att ch facility receipt) Date
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