HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 134 CROSSBOW LANE 4/10/2025 Commonweal h of Massachusetts Town of NOrth 4 ndo Ver
City/Tc T�)rf4-\ An cJ ovfv APR 23 2025
A System Pumping Record
.Z.
. ..... Form 4 Health Depa
ttrnnt
DEP has provided this form for use by local Boards of Health. Other forms may be used, but thee
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 CIVIR 15.351
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
----------
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code
2. Syst Owner:
77
Name
.......... ......................... ------ .. .........
Address(if different from location)
.................. ------.......... --------------
City/Town State Zip Code
0 J CC, 3
Telephone Number
B. Pumping Record
1. Date of Pumping D 11 at I a 2. Quantity Pumped: Gallons
3. Component: F1 Cesspool(s) ["Septic Tank r-1 Tight Tank ❑ Grease Trap
F-1 Other(describe): -- ............. ..................... .........................
4. Effluent Tee Filter present? n Yes M No If yes,was it cleaned? ❑ Yes ❑ No
5. Observed con1tion of component pumped:
................ ............................... ............ .......... ------------- .........
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
❑ .......... ............. -----------------------
'7.
Si I g-n r <uer Date-
------------ ........... .............. ................. ..........----—-------------
Sign t R6iving Facility(or attach facility receipt) Date
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