HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 427 WINTER STREET 4/20/2026 Tow
n of Nor ndov r
Commonwealth of Massachusetts APB 3 0 202
ti a C'ty/Town of
ystem Pumping Record Healthenf
,W Form 4
DEFT 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 farm, check with your
local Board of Health to determine the form they use The System Purnping Record rnUst be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 (,MR 15,351,
HOUSE: front ack side rear left rip Drit
A. Facility Information BUILDING: front back side rear left ript,ht
Important; When
DECK: under
(filing out forms 1, System L.oC21tlon'
an the cornpulor,
use only the tab
key to rnove your Address
cursor-do noI �y - MA,
risethe. re(urn "r.c}- _,_.._.__ ___,....__.._ .__,_. _.... _.. w_ . _ . . ___.-._ _. _.__..__. .._ ._..._ --------
key ..
C wn S, ale Zip Code
2. System Owner:
Name _
inirnr';X 4l�
Acldrnss (If rJiNereni fror,i location)
MA
City�l�awn �31ate Z-ip Cod€;
Telephone Number
B. Pumping Record
1. Date of Pumping 11.�_�_,_'_ _....__ 2. Quantity PLJrnped: -----
Gallons
r
3. Component: [] cesspool(s) Septic Tank ❑ Tight Tank ❑ Gre.ase Trap
[1 Other, (describe): _ _.___._ _._....._ _ .._,__._ ___.____ _.__-_..___..___...---._.....
r
4. Effluent Tee Filter present? F] Yes ] No If yeas, was it cleaned? [-] Yes
._) No
5. Observed condition of component purnped:
(S. System PtAmped Fay:
(gave Tlney._.._........_.... E�2S Au
s 1 g Mass 1AD317_Name Vecic License urnbe.r
Bateson Enterprises, Inc
._._
Cornp>any
7. L n where contents were disposed:
GLSD
Sign tur Hauler Date
Signature of Receiv{ny f acility(or attach facility receipt) Date
t5forrn4.doc- '11(12 System Pumping Record Page i of t