HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1476 SALEM STREET 4/6/2026 Town of lh An
Commonwealth of Massachusetts Noldover
City/Town of �j, Pkr\A(,,,c v,
SYstem Pumping Record APR 13 2026
fur Form 4
Heah DEP has Provided this form for use by local Boards of Health. Other forms mayltuses
be anbut the
information must be substantially the Same as that provided here. Before using this form, check with your
local and 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 CIVIR 15.351.
A. Facility In—fo—rm a—,i—on—
Important;When
filling out forms I. System Location:
on the computer,
use only the tab I j av&
key to move your Address
cursor-do not
use the return ----------
kay,
C!Wown
State
2. System Owner: Zip Code-'
Name
Address(if—dlffere—n1 from—location)
----
C'Yfrow—n--------- -ZIP—Cod_------
B. PuMping Record "telephone—Number ----------
—
1. date OfPumping
Date 2. Quantity Pumped:
3. Component: Gallons
0 Other(describe):0 CessPOOI(s) Septic Tank 0 right Tank n Grease Trap
4. Effluent Tee Filter present? [j Yes El No If Yes, was it cleaned? EJ Yes 0 No
5. Observed condition Of component Pumped:
. Sys
jem Pumped By:
Name
Vehl Uoense Number
Oorrl any
7. Location where contents were disposed:
L<,Q
Sign ure of Hauler
Signature of Receiving Facility(or attach facility receipt)
ch la
Cate —---------------------------
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