HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 7 DUNCAN DRIVE 11/11/2025 Town of NOrth
ConimanwaaIth of Massachusetts Ve
City/Town ofNo V 14ZO
25
System Pumping Record
a� w Form 4
D",
DEP has provided this form for use by local Boards of Health. Other forms may be used, b e
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. __... ..._._. .___.. -. _-_._._. _.. _ _ _._.
iC7USC: front cl< side rear left; ri5ht
A. Facility Information Eiult_fDING: rMcSnt back side rear left right
7�CK: under
Ifll r76rtant; When
filling out forms 1, System Location,
on y thputer,
o
Use only the tab
key to rnove your ddre a _
cursor-do not MA
use the return __.....,_ - _ - ._... . _._ _ ... �. ._.__----- _. _____ —_.
Kcy. Cityfrown State Zip Code
2. System Owner:
` f
_- . -�
__
Nam._ _.
e _
Address (if different from location)
MA
Cily(Tov✓n State � lip Coclr,
Telephone Number
B. Pumping Record
1, Date of Pumping ___-- .---. .._. 2 Quantity Pumped —
CYate Gallons
3. Component: [ Cesspool(s) [peptic Tank ❑ Tight Tank [] Grease Trap
C� Ott)er (describe): ......
h, Effluent Tee Filter present? C] Yes ( No If yes, was it cleaned? (❑ Yes ❑ lVo
5. 07bserved condition of component pWI-)l)Eird -
5. Syst rr Purnped By
(3a e Tlney _._. Mass 1AA95B Mass 1AD31Z
Plane Ve lCle t.ic nc Numb r
Bat T terprises, inc
Company
Loan wh Rents ere disposed:
7ognature of Hauler (Date
Signature of Rec=iving -acllitY(or attach facility receipt) Uate
t5form4,doc• 11/12 Syste rn Purnping Record •pagc 1 c,,f 1