HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 520 SHARPNERS POND ROAD 12/10/2025 'ro" Of NOTM AndOver
'C� Commonwealth of Massachusetts MAR '-2
City/Town of Mr* A+1 206
dovc,C-
System Pumping Record Heahh Department
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
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.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, "(-5
use only the tab - -- ..........---------------------------- ---------
key to move your Address (
cursor-do not i -li� D164!�
use the return --------�- ( ........... .......------
key. City/Town 'State Zip Code
2. System Owner:
----------------
Name
Address(if different from location)
------------------------
-6�I ITow.n State _Zip Code
C
Telephone Number
B. Pumping Record
1. Date of Pumping Z Quantity Pumped-. lstyc>
Date Gallons
3. Component: M Cesspool(s) [Septic Tank F1 Tight Tank M Grease Trap
[—I Other(describe): - I I—-------I..................... -—-----------------------------------
4. Effluent Tee Filter present? Fj Yes QAo If yes,was it cleaned? M Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By: l(so
-Narne vehicle License Number ............
L4
Company 7
7. Location where contents were disposed:
---------- -------
.............
---
Signatureauler Date
--------------
------------ facility--------------
signature o iceiving-F6'cility(or attach ' receipt) Date
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