HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 350 BERRY STREET 11/7/2025 Commonwealth of Massachusetts Town of N00 4ndoVer
(_ City/Town of _
S s to rrt P u mp i n g RecorciNOV 202
7
y
� 1 Form 4 He
alth Mir
DEP has provided this form) for use by local Boards of Health, Other forms may be used, buf t I
information must be substantially the same as that provided here. Before using this form, check with your
Boca! Board of Health to determine the form they use. The System Pumping Record roust be submitted to
the local Board of Health or other approving authority within 14 days from -he purnping date in
accordance with 310 C M R 15 351 ___ _
OUSE i
back
real,
A. Facility �rlfdt"r7'►�tld_t1 est�it,r�iNC7 _.__-front� baek side rear I �tn4 y eft rigr,l
important: Whan DECK: u11de1,
(INog out(orms 1. System L.ocat�o n:
use
the cornpufer,
us
e o�71y the lab
key to move your Address
t _
cursor-do not
use (tie return ... _.... �._. __.... _._....._
key, Cllyli:own Slate lip cocie
2 System Owner:
�- �)at�`�` f l a
BILY/I9Fy,4�'
Address (if different frorn location)
M A,
C;[yffowr1 — .__. Slat
Telephone Number
B. Purnping Record
1 Cute of fourn pint - - tt
( C>at� --- Quantity Pumped: _...._._____.._._..._..
Gallons
3, cornponerrt. Cesspool(s) [ eptic I-ank Tight Tank ❑ Grease Trap
[] Other (describe) --- ___ __.----__ ........___.�_
4. Effluent Tee Filter present? 0 Yes [_ No If yes, was it cleaned? [_] Yes [] No
5. Observed condition of component purnped: /'
6 .. � .._._..
F ,rrr p c.c1 By
)eve i inc,y Mass1AAg5E Mass 1AD31f_
arie Ve;f7it;le !_Irfvnse 11 E3ate on E nter,orises, Inc.
7- Lc afior vvftert', contents w pe disposed:
Sigr7ature of Hauler Dale
.Sigrratu(e of ke,ceiviny f aCllity (or atUa<.Y) (,ac'plrly rec;ecpI) _ )ate
iblorrrr4 Cioc` 11112 S)ys(em f't,rrrrping Record ` Page 1 (:)l 1