HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 991 JOHNSON STREET 9/23/2025 Town of forth�
4 Commonwealth of Massachusetts ndover
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_5 ' �� City/Town of
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-__ System Pumping Record 5
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`e. Form 4
Health
DEP has provided this form for use by local Boards of f iealth Other forms rnupygg t the
information must be substantially the same as that provided here. Before using this form, cieck with y
focal Board of Health to determine the form they use. The System Pumping Record must be submittee
the local Board of Heaith or other approving authority within 14 days from the pumping date In
accordance with 310 CMR 15.351 ---- - ----
HOUSE: frontcl 'sidA f
.__.. _.— _ _._..
A. Facility Information BUILDING: front back side rear Icf
DECK: under
Important:When
filling out forms 1. System Location:
on the cornpu(or, (/�
use only the lab _.-----
key to rnove your Address *�
cursor-do not �( " ,G MA �ti
¢ use the return -- — --- L - —_. _._—_--.___ .. ---. _. T—_
key. CityFrown State Zip Code
IV/
Ll�l
2. System Owner
a-J"Ell
Name
re
Addrass (IF different from focatlon)
MA
Clryrl"owr7 Sta / �r ��. ZI p—
Code
Telephone Number
B. Pumping Record C
1 Date o f f�a rn p i n g —-_ 2Quantity P u rn p e d.
Oatc; Gallons
3. Component: ( ] Cesspool(s) [ tic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe), __.-----__-- ---._.-.____------------------------_.
4. Effluent Tee Filter present? ] es o If yes, was it cleaned? [ Yes ❑ No
��p.
5. Observed condition of cornponent pumped
-----
6. Syste Ramped By
( aye They t,. Mass 1 AA95E M s 1 AD317 `
Marna Vehicle License Nurnber _-_._.__....
-6-ateson Enterprises, Inc.
Company
7, L cation where co,rL a ;w.. disposed Slgnatur9 of Hauler Date
Signature of Receiving Facility (or attach facility receipt) Date -
t5form4.doc• 11112 System Pumping Record - Paq, 1