HomeMy WebLinkAboutSeptic Pumping Slip - 2024-06-27 - Septic Pumping Slip - 34 ROSEMONT DRIVE 6/27/2024 Town of
Commonwealth of Massachusetts
'VOrth 4ndover
FEB City/Town of � ; ' 2
System Pumping Record �t
- Form 4
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,
use only the tab _ -__-- _ - ALP
key to move your Address _
cursor-do not 8
usethe return - -. .. ..M --... ....._..- ---.__._._....- -.... - -- - -- -- ---...-... -._.... '- ---.....-._....
key. City/Town State Zip Code
2. System Owner:
f r,
Name
n
Address(if different from location)
City/7own State !!Zip Code
114
:. -
Telephone Number
B. Pumping Record
1. Date of Pumping ..._.....ate----------- ' ---..._..____-_. 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 condifon of component pumped:
6. System Pumped By: r
me Vehicle License Number
ompany
7. Location where contents were disposed:
- -- - --..................-- ...._............ --------..............._ _._..__...__.. ----...._.-_.._..__...
sign re of auler` Date
........_..._------. _.. ...... ..... ...._. _. ..
Signature of i ity(or attach facility receipt) Date
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