HomeMy WebLinkAboutPumping Slip - 161 Raleigh Tavern Ln - 01/14/2025 - Septic Pumping Slip - 161 RALEIGH TAVERN LANE 1/14/2025 oft
Towncill
Commonwealth of Massachusetts JAN 2 7
City/Town of 1� 2025.,�-j , 0 v-,JA c
SYStem Pumping Record
Form 4 Health
DEP has Provided thitform for use by local Boards Of Health. Other forms may be used, but the
information must be substantially the Sarno as that provided here. Before re using this ec
fb g s n s form, ch k with your
local Board of Health to determine the form they use, The System Pumping Record must be U itted to
i
the local Board of Health or other approving authority within 14 days from the Pumping date s bm
accordance with 310 CHAR 15.351. n
-F-a—c—il I ty I—nf q r rn-a t 1 o n
important:When
fiffing out forms I. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return
key, Cityrrown State
2. System Owner:
Name
Addnsss'If different ftiomIxa'tion)
Zip Code
fiieWo�e Number
B. Pumping,Record
1. Date of Pumping --L/—Iq h 2. Quantity Pumped:
Date
6ellons
3. Component: 0 Cesspool(s) Septic Tank El Tight Tank n Grease Trap
n Other(describe):
4. Effluent Tee Filter present? 1:1 Yes 0 No If yes, was it cleaned? n Yes 0 No
5. Observed,condition of component Pumped:
& System Pumped By:
..ni
Vehicle Ucense Number
r-rL---
Company
7. Location where contents were disposed:
Tli-J&i Of"Hauler
-Date
Sign re of ivi Facility(or aiiiai-fid-Fit-y—receipt)
t5form4.doc-11/12
System Pumping Record-Page 1 of 1