HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 31 SUGARCANE LANE 4/6/2026 Town of North Mdover
Commonwealth of MassachL.asetts
City/Town of APR 13 2026 System Pumping Record
Form a Health Department DEP has provided this forrn for use k)y local Boards of Health. Other farms may be used, but th(-,;
information must be substantially the sarne as that provided here. Before using Ihis form, check will) 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 wlihin 14 days frorn the pumping date in
accordance with 310 CMR
15,351
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rear I e f right-fr.c t
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A. Facility Information BUILDING: front back side rear Ieft
Important: When
DECK: undei,
filling out forms 1. systern Location:
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key CityfFown State Zip Code
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Address if different from location)
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c,ityfT"own ip Code
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Tr lf-phrone Number
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l3. Pumping Record
ry
1, Date of Pumping 2 Quantity Pumped: - --.
rJalr Gallons
3. Component: [ cesspool(s) 2_ tic lank (❑ 'Fight Tank ❑ Crease Trap
[.� Other (describe)- _.._ ______...
4. Effluent Tee filter present? [_] Yes No If yes, was it cleaned? ❑ Yes ( -) No
r. Observed condition of component purnped:
" SystamyF�impc;ci Fay:
Ma
C7ave Tlne t 1l�A 5E Mass 1F D31T_
_ ...,. _
"� rTu� �.„.�^ Vt.hlr,le t_�c,ensc, urnbe;r -
Bateson E_nterprises Inc.
l,orrtpany
7. oc -. disposed°°°c�fi wl.��.f .�., c>h,tt�rlt were disposed
vL SD
Slgr), Date
Signa(ure of Rr r civ{rry Facility (or altarh facility rc4w"ipt) Date
t5form4,doc• 11t11 System flurnping Record p'a<1e 1 of 1