HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 91 FULLER ROAD 5/7/2025 Commonwealth of Massachusetts Town ofNorth hover
City/Town of MAY 15 2025
.k M
System Pumping Record
Form 4 Health:r .. epa rl"1 '
C>EF� l-tas provided this forn'i for use by local f_uoarr,,s of hier�ilth Other fori-ns may be used, t>rl�ie
information must be st.rbstantially the sarne as that farovirir.,d horn, Before using This form, chuck with you(
local Board of Health to determine the form lhey use, The `system PLImping RecoW must bo suhmitle(f to
the local Board of Health or other approving.,) E3uthori(y wifhin 111 days from the pun,)ping date io
accordance with 310 CMR 15.351 ----
__.___ H 0 U S E fro back side rear le i t
A. Facility Information BUILDING: front i-,)ack sine rear left ri�tu
Important: When C ECK nder
(filing out form,' 1 SystemXl'
rr
on the compt'aw, C?
USE! only the fah
key to move your Addra ss ,,yy
cursor-do not fViF\ 4�
use the return --..__ __ .-_---------.._ _____._ . _,.._._ _______
key, Cityrrown w�Ea(e Zip Code
f 21 Systern Qwner:
Address(If different from location)
M_A
CIt (Town __...__ ......_ _. --...
Y Slate rip nod
Telephone Nurnbe,(
B. Pumping Record
` ._ . _ —
1. Date of Pumping .____. ...____..__.____ ? Quantity Pumped. -----------.. _._
Bair% Gallons
3. Component: ( ; Cesspool(s) Septic Tank C Tank'Fight
C� � Grease Trap
Other (descrjbe) _ . .
4. Effluent Tee Filter resent? Yes halo If yes, was it r,,lF;rjned? Yes i_�,7 No
5. Observed condition of cor-nponent purnpecl:
5. Systern P(jmped By:
Dave Tlne Mess 1AAP5E ,ass 1/k-D31
Name Vehicle license Nurr er
�afesnn �nfe�rprlses, .lnr
Company
7. L tion where contents were disposed
...._.. _.__ �1
Sl nature of H<.aulei CJale -
Signature of Recolving acility (or attach facility receipt) Dale _..__..
l5form4.doc. 11112 Syr3te`r`n P(mving Reror(i f,'acte� 1 of'1