HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 BROOKVIEW DRIVE 4/20/2026 Commonwealth of Massachusetts Town ofNor till over
City/`Town of
F APR 3 0 2026
- stem Pu
mping umping Record
LL Forrn 4
Health Department
DBP has provided this form for Use by local Boards of Health, Other forms may be used, but the
information must be substantially the same is that provided here. Before using this fort-n, 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 ,he purnping date in
accordance with 310 CMR 15.351
HOUSE: rc.]n t ,Ack side 1e t�,rear 5ight
A. Facility
Information BUILDING: ront hack side rear left right
Important: When DECK: Undf'r
on filling out forms 1 System Location
atlon
on ' !
the computer,
use only the tab
key to move your Address
cursor_do no( t g
use the return ------- ._ _.,- ..____.. _._ _._._.Y._?_. MA
Cliy7rawn __
key. S(We ZipCade .. ._-__.__ .._..__...
1
2. Sy tern Owner
4 1 an� _..._..._
1611-111—
Address (U different (rarr7 location) ---.._..._ ..__..____ __... _. .....
----- M A
--
acr ( lip Codfr. ....
Telephone Kurz-ot,5er
B. Pumping Record
1. Date of Purpling ..._.. ___ ___... 2. Quantity Pumped
Gallons
3. Component: Ej Cesspool(s) ( �eptic -Tank Tight Tank ❑ Grease Trap
Other (describe): _.... ____...._
4. Effluent Tee Filter presant? Yes No If yes was It cleaned? Yes ❑ No
5. Observed condition of component pit ec
L.
---- .
6. S ern Pumped By
Dave Ti Mass__._--_--_ _-_-- _._..- _..__ . _ __.... _. Mass 1A1i95E� Mass iAD317_
Narr7e Vehrcie l.lcense C`J .ether
rr,m pany
7. Loca ion e nten s were d�sas s°e'd
GLSE
Signature of Hauler Date
__......
Slgnalruc of Receiviny Facility(or attach facility re.crvirrl} [:rate„ --
15form4.doc- 11112 Systern Pumping Record - Page 1 of 1