HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 445 FOREST STREET 6/2/2026 �L\ Commonwealth of Massachusetts Town of lVOrth AndOVer
City/Town of
JUN 15 2026
System Pumping Record Health
Form 4 DepartMent
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,
use only the tab LA SA
............. ...............................
key to move your Address tt
cursor-do not A
use the return
key. 6-'4/T/�o w n State Zip Code
2. System Owner:
VQ U"C -kIr
-----------....................
Name
awn
Address(if different from location)
City/Town State Zip Code
ephone Number
B. Pumping Record
1. Date of Pumping 06 1 2. Quantity Pumped.
Date Gallons
3. Component: M Cesspool(s) ED/Septic Tank E] Tight Tank R Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? M Yes [ No If yes,was it cleaned? R Yes F] No
5. Observed condition of component pumped:
-0,d------------------------ ............................ --------------------------------
6. System Pumped By:
"Nr C"I �0�p q 1-7 0
.............—..........
Name —Vehicle License Number
A:
Company VA- 'V
7. Location where contents were disposed:
gta
01i
pre of H
I
.............a Date
----------
Signature of Receiving Facility(or attach facility receipt) Date
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