HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 313 SUMMER STREET 4/21/2025 Own of iVorth 4ndOver
Commonwealth of Massachusetts
City/Town of APR 28 2025
P System Pumping Record Hea/ti,
Form 4 DePartn7ellt
DEP has provided this form for use by local Boards of Health. Other fo(rns may be used, but if)(--,
information must be substantially the same as lhat provided here. Before using lhis form, check wiIh your
local Board of Health to determine the form (hey use The System Pumping Record rnust be submitted to
the local Board of Health or other approving authority within '14 days from the pumping date in
accordance with 310 GMR 15.351,
------ ------- HOUSE: front(bbaciside rear left (r I
A. Facility Information BUILDING: front '6a"5` side rear left rlg�(
Important:Whon DECK: under
filling Out forrms 1. System Location:
on Ihe computer,
use only the tab
key to MOVe Your Address
Cursor-do not
use the return —MA
---
key, Zityffown Stale Zip Code
2. System Owner:
--(�Tqrn e -------------
Address (If different from location)
M A
CRY/Town State q7i Zip Code
Telephone Number
B. Pumping Record
2. Quantity Pumped�
1, Date of Pumping -Gate Gallons
3, Component: Cesspool(s) ❑ Septic Tank 'Tight Tank ❑ Grease Trap
0 Other (describe),
4, Effluent Tee Filter present? 0 Yes No If yes, was it cleaned? Yes ❑ No
5, Observed cond (10 component
6, System Pumped By,
Dave T ney ...... ...... Mass 'I AA95 E---4-"-6 s_1-A-PI
Name VeTTc-e t-L--ic—ense
@a egorl
Company
7, (5 .
lion whQre contentswore di5po5cd;
- —-----
i e'
Signature of Hauler Date
Signature--�—D�—eoe�lv �g�— a—ci 11—ty Date ------
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