HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 196 SUMMER STREET 12/20/2024 Commonwealth of Massachusetts TOWil of N ndover
City/Town of
BAN 7 2025
System Pumping Record
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 lhis 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 CIVIR 15,351,
------- HOUSE: �;Drontk back side rear �r i p,h t
A. Facility information BUILDING: Tront back side rear left right
Important:When DECK: Under
fIllIng out forms 1. System Location:
on the computer,
use only the tab
............
key to move your Address
cursor-do not MA
use the return
key, City/Town state Zip Code
IQ 2, System Owner:
hf Name
Address(If different from Iccatian}
MA
CIty(Town
ok State Zip Code
Telephone__Number
B. Pumping Record
2, Quantity Pumped,
1, Date of Pumping at
Gallons
3. Component: ❑ Cesspool(s) Septic Tank Tight Tank ❑ Grease Trap
[I Other (describe):
4. Effluent Tee Filter present?// Yes ❑ I\jo If yes, was it cleaned? Yes [I No
5. Observed condition of component purnped,
Q0 ------ --------
6. System Pumped By:
Dave Mass 1AA95E ass 1AD31Z
Name Vehicle License Nurn
eateson Enter rises, Inc.
Company
(r 4ion where contents were disposed:
C3;L's I-i —------
lu
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Crate -
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