HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 81 CANDLESTICK ROAD 10/7/2025 Commonwealth of Massachusetts Town Of North 4ndoVer
City/Town of
OCT
I Sys tem Pumping Record 7 2025
Form 4 e'-
Dc�pjrtr .�.n
DEP has provided this form for use by local Boards of Health. Other forms may be used, but, 4t
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 16.351.
HOUSE: cfr-olh-t---�ack side rear(Le�_,.,rjjht
A. Facility Information BUILDING: fRP)T-oack side rear left right
Important:When DECK: under
filling out forms 1 System 1.OC21tion:
on the computer,
use only the tab —------
key to move your Address
cursor-do not
use the return MA
key, City/Town State Zip Code
2. System Ow er-
...........
Name
lawn
Address(if different from location)
MA
CiryCtown State —1Z775
'r j
Telephone Number
B. Pumping Record
2. Quantity Pumped,
1. Date of PumpingDate Gallons
3, Component: ❑ Cesspool(s) Septic Tank0 Tight Tank 7 Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? 7 Yes. �No If yes, was it cleaned? M Yes 0 No
5. Observed condition of component pumped:
6. Sy tern limped By:
r
�y
y
D ve Tine MasslAA95E Ma s IAD31
jNm a Vehicle License Wt er
B__.es
Company
7. La ation where contents were disposed:
L
Date
Signatureattach facility receipt) Date
- —
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