HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 82 LIBERTY STREET 9/19/2026 Commonwealth of Massachusetts Town of No dover
City/Town of L�
System l Pumpiug Form 4 ng Record AUG 2 5 2026
toe
erpith Department
DEP has provided this form for use by local Boards of Health. 0 r Orms may a used but the
information must be substantially the same as that provided here. Before using this farm, 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 15.361.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab '�'z'(-)-
key to move your Address "J
cursor-do not
use the return
key. Ulty/lOW11
State
2. S stem Owner.
Nalliv
iaam
Address(if different from bcation)
CW ro—wn————————-——————
State
Zip Code
B. Pumping Record Telephone Number
1. Date of Pumping Date > 2. Quantity Pumped:
3. Component: fans
0 Cesspool(s) El Septic Tank rl right
0 Other(describe): Tank ❑ Grease Trap
4. Effluent Tee Filter present? 0 Yes C1 No If yes,was it cleaned? El Yes 0 No
5. Observed condition Of component Pumped:
6. System Pumped By:
Vehicle Ucense Nu"07/1" A J�'Ijl mber
Company
7. Locati where contents were disposed:
Sign rme"f Hauler
Date
Signature of Receiving Facility or attach facility receipt) I pate
t6fbffn4.doc-11/12
System Pumping Record•Page 1 of 1