HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 79 GRAY STREET 4/16/2026 1C\ Commonwealth of Massachusetts Town ®f NOdh ArIdOver
City/Town of rA4A Anclov'C"'r JUN 15 2026
System Pumping Record
Form 4 Health D,partMent
DEP 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 CIVIR 15.351
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
ruse only the tab1ra........... ...... .................................. ......................................-
-1 - _---C
key to move your lAress
cursor-do not iN's
use the return -,
key. City/Town State Zip Code
VQ 2. System Owner:
c ......................... ---------------
Name
----------
Address(if different from location)
City/Tawn ....................... State- Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping -Date- 2. Quantity Pumped: Gallons
3, Component: M Cesspool(s) 2/septic Tank ❑ Tight Tank F-1 Grease Trap
F-1 Other(describe): ----—------------------------------------------------------------------------------------
4. Effluent Tee Filter present? r-1 Yes 2""No If yes, was it cleaned? [] Yes E] No
5. Observed condition of component pumped:
..........&- -d.............................. ...............-1--.....................................
6. System Pumped By:
r ....... -- -....- ---------- ---------
a
Na e Vehicle License Number
Company
7. Location where contents were disposed:
Signaa uree of "a"-ule Date
a�f
- ---------- ------------- ------------- .................
ignatu ceiving Facility(or attach facility receipt) Date
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