HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1001 JOHNSON STREET 6/9/2025 Commonwealth of Mass TOWn Of NarthA
Massachusetts ndover
7 _ - City/Town of W, JUL
LL 10 20 System Pumping Record
25
s
Form 4
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DEP has provided this form for use by local Boards of Health. Other forms may be ueq,
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 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, g'
use only the tab 1 "`t c p1 6rt/
key to move your Address -- ----
do
cursor- Cit / own c,r .
use the return not
_ . ____..._...___..._______-.
key, y State Zip Code
2. System Owner:
Name
emu,
Address(if different from location)
._--
CitylTown State Zip Code
C,
Telephone Numbr �17
B. Pumping Record
1. Date of Pumping Date -- — 2. Quantity Pumped: Gallons -
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): .._. .......
4. Effluent Tee Filter present? ❑ Yes No_ If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Name Vehicle license Number
Company
7. Location were contents were disposed:
C1 V
Signature of MauferN " Date
Signature of Receiving Facility(or attach facility receipt) Date
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