HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 416 RALEIGH TAVERN LANE 2/13/2024 � Commonwealth of Massachusetts Town North Andover
City/Town of
System Pumping Record
FEB 13 2024
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, butthe
information must be substantially the same as that provided hero.•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.
A. Facility Information
Left/Right front of house, Le(/Right re r of house, Left/Right side of house, Under[
Important:When 1Address"_.0QN
m L : Left/Right side of building, Left Right ront of building, Left/Right rear of building,
filling out forms
on the computer,
use only the tab
key to move your �
cursor-do not �V/> /,�L11. MA
use the return City/Town State Zip Code
key.
2. S ste wner•
reb
r
Name
rerun .
Address(if different from location)
MA
City/Town State Zip Code
3
Telephone Number
B. Pumping Record
1. Date of Pumping zo)�
ate - 2. Quantity Pumped. allons
3. Component: ❑ Cesspool(s) (:;4eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): —
4. Effluent Tee Filter present? ❑ Ye )- 440 If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped-
6 System Pumped By:
Dave Tiney Mass F5821 A'#95C'
Name Vehicle License Vumber
Bateson Enterprises, Inc.
Company
7. L atlon wh re contents were disposed:
LSD
Signature of HauIV Date
Signature of Receiving Facility(or attach facility receipt) Date
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