HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 103 TUCKER FARM ROAD 8/1/2025 Commonwealth of Massachusetts Town of North An
City/Town of
System Pumping Record
Form 4 AUG 12 2025
DEP has provided this form for use by local Boards of Health. Other for%q"bq..�sed,.but the
information must be substantially the same as that provided here. BefJj 6 your
local Board of Health to determine the form they use. The System Pumping Record must be"sued to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351
HOUSE: 1/frohft❑ ack side rear left right
A. Facility Information BUILDING: f"back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Ad Vre,s
cursor-do not 1 '0& MA
use the return :7A -§tate -- Zip Code
key. City[Town
2. System Owner:
Name
V
Address(if different from location)
MA
CityfTown State i S ode Zip
-"q, Z
Telephone Number
B. Pumping Record
1. Date of Pumping Date2. Quantity Pumped: Gallons
3. Component: 7 Cesspool(s) 2"Septic Tank 7 Tight Tank ❑ Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? Fj Yes No If yes, was it cleaned? F Yes ❑ No
5. Observed condition of comp vent pumppd:
6. ystem y" ped By:
ave Tin Mass 1AA95E M ss r1AD3
ame Vehicle License Number 111.
to n Enterprises, Inc
Company
7. 0 ca-ti where eFsrr were disposed:
G L
Signature of-Hauler Date -4
-Signature of Receiving Facility(or attach facilityreceipt) Date
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