HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 450 BOSTON STREET 4/15/2026 Commonwealth of Massachusetts Town of Nor in Anilover
City/Town of
ri System Pumping Record APR 17 2026
Form 4
Hea
IDEP has provided this form for use by local Boards of Health, Other On h t lhe
inforr-nahon must be substantially the sarrie as that provided here. Before using this form, deck with your
local Board of Health to determine the form they use. The System Pur-riping Record must be submitted to
the local Board of Health or other app(ovim, authority within 14 days from *.he purnping date in
accordance with 310 C M R 15.351.
HOUSE: front back CSIL(�)rear
A, Facility Iriformation BUILDING: front back side rear left ri
Important:W I hen DECK: under
(Illing DW fOMIS 1. Syste(-n,LocatiQn
on the computer,
use only tho (ab Ate- . S k
key to rnove your Address
curso( do not MA
use the re(um —----------
key, CilyrFown State Zip code
2. Sy Owner:
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N a m e
----------- -—------
Aodfe,5s (it oifle(oof from location)
DWI Sla(e a ip Code
Telephone t amber
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B. Pumping Record
/
1 Date of Purr-tiping D 2, Quantity Pumped. Gallons3, Component. Cesspool(s) 6'Septic Tank ❑ Tight Tank
Grease Tr@p
Other (desci-ibe), —-------
4. Effluent Tee Filter present? �es "(.-] No If yes, was it cleaned? No
5, Observed condition of compooerfI purnped
6. S em f��j*ped By.
ave Tine Mass IAA95E M s 1AD31Z
Vehicle License Number
aleso rprises, In(.,.
ELI k<e--------
Con-ipany
7 L on'cati h c�ef,� contents wne disposed�
,a 01,
G L5 D
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Signature of Hauler
g atufc of Receivlog'Facility (or jitaci) f,,,cij,(y jpl)oi
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