HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 212 HAY MEADOW ROAD 4/4/2025 Commonwealth of Massachusetts TOM7 OfNcr'h4ndover
City/Town of
APR 4 2025 System Pumping Record
Form 4
k
1('4alth D
DEP has provided this form for Use by local Boards of Health Other forms may be used
a ,s that provided here Before using this form, check with y 1olf
information must be substantially the same OOMe
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,
HOUSE: front eack side rear left right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location;
on the compul8r,
use only the tab
key to move your Address
cursor-do not
use the return k� ---------
key, CityfTown State Zip Code
2. S stem Owner:
S
Address (if different from location)
MA
------------------
CtyfTown State Zip Code
Telephone Num ber
B. Pumping Record
ALt�
1, Date of Pumping ?—f 2. Quantity Pumped,
YaleGallons
3. Component: ❑ Cesspool(s) Septic 'Tank ❑ 'Tight Tank ❑ Grease Trap
[] Other (describe)
4, Effluent Tee Filter present? 0 Yes / No If yes, was it cleaned? ❑ Yes [D No
5. Observed condi 'on of component purnped,
6, System Pumped By,
Dave M ss 1AA96E) Mass 1AD31Z
I- �Dc
Name (�V�ehlcle License Umber
eateson Ent: rj�ses, Inc
Company
T tion where contents were di5lbQsed,
to(C3LSD
:�0-
Signature ofHauler
Signature of Receiving f��6irT;(or attach facility receipt) Date
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