HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1493 FOREST STREET EXT 10/20/2025 (3) 4
Commonwealth of Massachusetts Town Of&'ofth 4ndaver
O
c City/Town of _ CT �, p
=� } System Pumping Record Form 4 Health
r you epartm,nt
DEP has provided this farm for use by local Boards of Health. Other forrns may be used, but the
Information must be substantially the sarne as that provided here. Before using this form, check with your
local Board of Health to deterrnine the forrft they use. The System Purnping Record must be submitted to
the local Board of Health or other approving aufficirity within 14 days fron7 'he purnping date in
accordance with 310 CMR 15,351,
ide
HOUSE (rj�)O back
Sear left g.,.
A. Facility Information sUILDINGi front back side re
ar right
lrnpurtarht'.When
DECK: u n d er
flfling out forrns 1 Systen') L.Oc atIC n
on the computer,
use onlylythethe (a b
key to move your Address
cursor -do not N1A
use; thie return _.__ �___ _ ._ - .__--
key clty(rown 51a1e Zip Code
I. System Ovvner
v� Name
P
rerar�J��
Address if ditferonl from !creation)
MA
CRy�ichwn _ .. Stale _.. _..
Telephone plumber
B. Pumping Record f
1. Date of ( urn ping __.... ._. "' _._. . ..
I J Dale Quantity Pumped.
Gallarhs
3. Component: (-_1 Cesspool(s) [%94eptic Tank Tight Tank ❑ Grease Trap
(� Other (describe) -_____. _____._ ._-___.__
d. Effluent Tee Filter present? (� ) Yes [�'No If yes, was it clearhed? ❑ Yes ❑ No
5. Observed condition of con"iponent I') rnf,-)ed.
6 -,y;ten-h Pumped By.
_ _ --- Mass 1A,A05E ass 1A :�11
fvarr = Vnfniclr, l.ir,Hr'hsr� Nrrrr~tber
�af�s��rt E�:r7(erisris�s, InC
Cc]rnfra�ry _
7 Lc a(ion where contents were disposed
G �Lr
S'egnalme of Mauler t a(e
Sfynalurc of Rec-eiving Facility(or aatt rr,t) facility receipt) Dale
t5forrn4.doC 11It"l. System F)umping f�ecorci page 1 of 1