HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 33 EAST PASTURE CIRCLE 4/10/2025 Commonwealth of Massachusetts To Wn of'Volth 4 ndover
22 2025
City/Town of AfD(.1 APR 41 *0
System Pumping Record
Form 4 Ilec-1,th Dopc
DEP has provided this form for use by local Boards of Health. Other forms may be u1seT,q0the
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 3?5
.............. ------
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code
2. System Owner
(9,
---------.................. ------ ------ ------------------
Name
-Xddh of--d iffe-r'e ni-fir-o-m-16cat—ion) ------ ------------------- --------
City/Town State Zip Code
-telephone Number
B. Pumping Record
1. Date of Pumping -Dat-e 2. Quantity Pumped: Gallons - ------ -----------
3. Component: F-1 Cesspool(s) Er Septic Tank El Tight Tank R Grease Trap
F-1 Other(describe): - ---- - -................------------------------ ..........
4. Effluent Tee Filter present? F1 Yes M No If yes,was it cleaned? M Yes R No
5. Observed condition of component pumped:
---- --------
6. System umpe y:
I CNf
be ' -- ----—---------------------------------
............
'Name Vehicle License Number
Company
7. Location where contents were disposed:
C
........
............................ ............................ ---—---------------------------
Sign4f, of a u 716r Date
-------------------........ ...................
Signature o bp 9.facq.ty.(orettach facility receipt) Date
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