HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 60 PATTON LANE 7/21/2025 Commonwealth of Massachusetts Town of North And
City/Town ofv,3,,,,v AUG 112025 '
SYStem Pumping Record
Form 4
Health Department
DEP has provided this forni for use by local Boards of Health. Other forms may be,used, but the
information must be substantially the same as that provided here. Before using this forni, check with your
local Board of Health to determine the form they use. The System Pumping Record roust 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 farms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not
Use the ratijrn AaLAi An dA2,
key. City/I own
State Zip
r'Ystem'Owrier:
TeiWh-one
B. Pumping Record
1. Date of Pumping z
-6,-te - 2. Quantity Pumped:
3. Component: n Cesspool(s) Lions
M Septic Tank 0 Tight Tank El Grease Trap
El Other(describe):
4. Effluent Tee Filter present? n Yes F] No If yes, was it cleaned? El Yes [--j No
5. 'Observed condition Of component Pumped:
B. System Pumped By:
C-
ZL N
Company
7. LOcant, where contents were disposed:
Sign ire`of Hauler
bi—te ----
V
Signature of Receiving Facility((attach aijai-jic
I;cOiPt) 7
t5forn,Wdoc-11/12
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