HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 134 GREAT POND ROAD 9/7/2025 Town of No�h over
Commonwealth of Massachusetts
City/Town of MAR -2 2026
System Pumping Record
Form 4 Department
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,
elcf
use only the tab
key to move your Address
cursor-do not '0 j '
use the return
_Avl-_ --------- --- - ----------
key. City ___State Zip Code
VQ 2. System Owner:
fiA Name
Address(if different from location)
... .............................
City/TownState Zip Code
----------01-74
Telephone Number
B. Pumping Record
............. ..........................
1. Date of Pumping .................. 2. Quantity Pumped:
Date Gallons
3. Component: E] Cesspool(s) 2"Septic Tank F-1 Tight Tank F-1 Grease Trap
F-1 Other(describe): ---------- -------------- ----------- ----—-----------------
4. Effluent Tee Filter present? n Yes No If yes, was it cleaned? ❑ Yes R No
5. Observed condition of component pumped:
...........----___.____._----—-----------------------------
. ................ ...................................
6. "§�tefn Pumped By: /11 1-7 C)
Te.'v-en4 r-cj ___ _..._GV'0C/ ____
... ............... -------
Name Vehicle License Number
Company
7. Location where contents were disposed:
............ -------- - -- ----
Signature of -ar ❑ Date
.......... -------- .............
Signature Receiving' Facility(or attach facility receipt) Date
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