HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 479 LACY STREET 4/8/2026 Town of No A
Commonwealth of Massachusetts O ndover
City/Town of 4.�,
System Dumping Record APR 13 2026
Form 4
�opartment
CEP 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,
use only the tab L
key to move your Address
cursor-do not 'l,�, --------
use the return A—1 --
lay. cityrrown
State
2. System Owner zip code
Name
Address(if different from loca#ion)
State
P�Code
Te-�--ho-ne-
6*—PU— in mp--9R—e`co—rd
1. Date Of Pumping h
3. Component. Del, 2. Quantity pumped:
EJ Other(describe):0 Cessi El Septic Tank E3Tight Tank 0 Grease Trap
4. Effluent Tee Filter present? E3 Yes El No If yes, was it cleaned? 0 Yes No
5. Observed condition Of Component pumped:
6. System Pumped By:
Nam am
Vehicle Lirnse Number
Company
7. Location where contents were disposed:
-w)
Sign of Hauler
Signature of Ql (orfacility---receipt)
Date
115form4-docill,11/12
System Pumping Record•Page 1 of 1