HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 147 JOHNNY CAKE STREET 7/22/2025 Commonwealth of Massachusetts Torn Of NO*AndOver
City/Town of
System Pumping Record AUG 112025
Forr-n 4
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DEP has provided this form for use by local Boards of Health. Oth he nformatIon must be substantially the same as lhat provided here Before using this forfck with your
local Board of Health to determine the forr'n They use The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from -,he pumping date in
accordance with 310 CMR 15.351,
-------- HOUSE: iron b ck side(r_ear 'left riF
A. Facility Information BUILDING: front-116-ack side rem"Teft rig
important: When DFCK: under
flillng out forms I Sys(ern Location:
on the computer, 'I
use only the tab
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2 Systern Ownerroan
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Addr®s
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Cily(Town State zip de
Telephone Number
B. Pumping Record
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1, Date of Purnjoing 2 Quantity Pumped'.Date- Gallons
1 Component: ❑ Cesspool(s) L�Septic Tank ❑ Tight Tank ❑ Grease Trap
LJ Other (describe).
4. Effluent -Fee Filter present? ❑ Yes ( �o If yes, was it cleaned? 0 Yes C] No
5. Observed cond (in o Cnponen[ pun_pV�/ __ __
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51_--S7,str,-n--t4?umped By
Dave Tine -------- Mass lAA95E- Mass 1AD31Z
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Narne Vehicle License Numb.
-Bale sjoa�ii[erlI)r Isps, Inc,
Company
)f; Ion where contents were disposed
-1 11, �
GL5D
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Signature of Haule( a(e
Signature or Receiving Facility (or attach facility receipt) Date
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