HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 96 REA STREET 6/26/2025 A\ Commonwealth of Massachusetts Town of No*AndWer
City/Town of Avdove,(
MAR -2 2026
System Pumping Record
Form 4
Health De p
DEP has provided this form for use by local Boards of Health. Other forms may be use , WMent
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,
use only the tab --- ----------
key to move your Address
cursor-do not 1f,16144, 4rk,-i0,f-,-
0 t
use the return
key. City/Town State Zip Code
2. System Owner:
A_t4- SCk-of
e
----------
Address(if different from location)
State Zip Code
Telephone Number
B. Pumping Record �o
1. Date of Pumping Date 2. Quantity Pumped: -dallons
3. Component: F-1 Cesspool(s) 01"Septic Tank Fj Tight Tank M Grease Trap
❑ Other(describe): ...... ------
4. Effluent Tee Filter present? ❑ Yes R-INO If yes, was it cleaned? R Yes M No
5. Observed condition of component pumped:
6. System Pumped By:
----z— 41b q 1-7b
------------- .........
Name-- y Vehicle License Number
56A N.'4b")f pull
Company
7. Location where contents were disposed:
------------...... ....................................... ...........................
........... ...................
a u of Haul Date
Signature o Receiving Facility(or attach facility receipt) Date
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