HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 674 TURNPIKE STREET 10/7/2025 OWn of
IVOrthA
Commonwealth of Massachusetts ndover
City/Town of ACT 205
System Pumping Record
- _ Farm 4 eal
DEP has provided this form for use by local Boards of Health. Other forms may be used, bufthe
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.
e,r rear le right_
HOUSE: front back si
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. Syst rn Location; L.
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return ___.._-.__._..__.___. .._ ..._..__-__...�__.
key, City/Town aJ Zip Code
rdLLL1
2. System Owner, t
Name
�er�un �l
Address( didifferent from location)
MA
CitytTown State Zip Code
Telephone
B. Pimping Record
1. Date of Pumping _-__ _ __..____ 2.. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Septic`rank ❑ Tight Tank ❑ Grease Trap
Other (describe): _____....
4. Effluent Tee Filter resent? ❑ Yes N M .
p o if yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of compone pumped.,
6. re
ped By: ,
Tine Mass Mass 1AA95E Mass 1AD31Z
Na Vehicle license Nurnbe
71
r rises, Inc_
7. lion where nt'�tats were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record •Page 1 of 1