HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 11 BRIDGES LANE 3/14/2025 Commonwealth of Massachusetts lown Of'VOrth 4ndover
City/Town of
R- APR -2 �025
System Pumping Record
Form 4
Health
?5
DEP has provided this form for use by local Boards of Health. Other forms may be bNith your
information must be substantially the same as that provided here, Before using this form, chetc
local Board of Health to determine the form they use. The System PLIMping 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 CM R 15.351
HOUSE: front ..aHk side rPa left right
A. Facility Information BUILDING: front 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
use the return --k—--A MA
CityfTown -------
key. Zip Code
104 D 2, System Owner:
--------------
N rT)e,
Address(If different from location)
MA
_C ------ _FyfT o;n State Zip Code
[3-3o'7'1
Telephone Number
B. Pumping Record
1, Date of Pumping 2. Quantity Pumped,
-bate Gallons _._____ __---
1
3. Component: F7 Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
E] Other (describe):
4, Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? 0 Yes ❑ No
5, Observed condition of component p rnlped,
6, System Pumped By,
Dave They Mass IAA95E ass 1AD31Z
Name Vehlcle License NiT')Ger---
Company
7, ation where contents were disposed.
GLSD
Signature of Hauler Date
Signature o-Receiving-------F-��f --------- Date
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