HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 344 RALEIGH TAVERN LANE 4/3/2023 Commonwealth of Massachusetts
RECEIVED
City/-1-own of —
System Pumping Record ff � �
Form 4
TOWN OF NORTpHRANDOVER
DEP has provided this form for use by local Boards of Health. 0theP9AQ_W �usedTbut 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. — - - -
HOUSE: front bac side rear ef�right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, L/ 11
use only the tab / Ql0 �g�orA �✓�
!i key to move your Address
cursor-do not ���akr � ICELr
use the return key. City/Town State Zip Code
i
2. System Owner:
4n1e 1te_ CcAL `n
Name
mwn
Address (if different from location)
City/Town . State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date L� 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present?)6 Yes ❑ No If yes, was it cleaned? ] Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
qGLD a'
3 1�-123
Signa Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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