HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1180 TURNPIKE STREET 5/8/2025 Commonwealth of Massachusetts, Town of North 4n
C ity/Town of AAY/1,A An el 6)L.,,e.-r dWer
System Pumping Record
Form 4 MAY 5 2025
DEP has provided this form for use by local Boards of Health. Oth ggjaVbe used, but the
information must be substantially the same as that providedIBe�o 11 IqpWj eck with your
local Board of Health to determine the form they use. The System Pumping Record mul(04tmitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Ad ress
cursor-do not
use the return .........
key. .Aty -own State Zip Code
2. System Owner:
VQ
Name
............------------------------
Address(if different from location)
State
-1 a — t c V
Telephone Number
B. Pumping Record
1. Date of Pumping
D 2. Quantity Pumped
ate ons
3. Component: ❑ Cesspool(s) septic Tank El Tight Tank F1 Grease Trap
Ej Other(describe):
4. Effluent Tee Filter present? [:] Yes No If yes, was it cleaned? ❑ Yes n No
5. Observed condition of component pumped:
--611-11--' &�twll) cl
6. §0jern Pumped By:
/--7
-- -----------------------------------
............ A0
Name Vehicle License Number
fCo m pa ny
7. Location where contents were disposed:
Q/N/i
Sig
-------------- ——----------------------------
--n-a--tu.r of auler Date
Signature of Re acil facility receipt) Date
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