HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1641 SALEM STREET 6/27/2025 rOwn
Of North 4nd
Commonwealth of Massacht.asetts OV�r
City/Town of __---- Jul
p System Pumping Record 24z5
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u
Form 4
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ePllrtlnent
DEP has provided this form for use by local Boorr s of Health. other forms may be used, but the
information must be substanlially the same as that provided here. E3efore using This form, check with your
local Board of Health to determine the form they use. The System Pumping Record Must be submitted (o
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
HOUSE: front back side rear left t
A. Facility information BUILDING: ront back side rear le(i right
Important: Whan DECK. under
(llling out forms 1. System Location:
on the computer,
use only t h o tad __—.__�� ----�-- ----_---
key to move your Ad ress
cursor -do not c�
M use the r e I u r n _—.___..
key Cityn'own Slate Zip Code
2. Sys rn Own
41�Q1___
Narrle
Address (If different from location)
MA
Cll /Town
Y Stale �j +� Zip Code
Telephone hJumber
B, PLImpincg Record
1. Date of Pumping - — - 3--____ ..___-_ 2 Q a n t i l P Lirn ��
Dale �, y p �e, Gallons
3. Component: ❑ Cesspool(s) (�j Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): —._—_ _/./--— --- -- --- --------------- ------.- -
4. Effluent Tee Filter present? [] Yes ) No If yes, was it cieaned? [ j Yes 0 No
5. Observed condition of component purnped,
0. System P ftmped By:
Dave Tlney Mass 1AA9SE X2SS 1AD31Z
Name Vehicle license Num er
L�
B a ew [n> n rpris ' Inc ---------`__--------
Company
7. n where contents were disposed()((o
-
Signalufe of Hauler
SI nalure of Receving Facility (or a a�h facility receipt) Cate
Worm4.doc- 11112 System Pumping Record Pape, 1 01 1