HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 344 RALEIGH TAVERN LANE 3/19/2025 Town of North Andover
Commonwealth of Massachusetts
City/Town of MAR 2 12025
System Pumping Record
Form 4 Health Depcirtment
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.
HOUSE: front back O�rear(��ght
A. Facility Information BUILDING: front back side rear e r,ght
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab (,err,
key to move your Address
cursor-do not
use the return MA
key.
City/Town State Zip Code
Id LID 2. System 0 2 r:
7 Cl(
Address(if different from location)—
MA
City/Town state Zip Code
--3V 2L
Telephone Number
B. Pumping 4Record ptMne�N�r�b�
1, Date of Pumping 2. Quantity Pumped,
DateGallons
I Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
Other (describe): ------
4. Effluent Tee Filter present? 7Yes No If yes, we,; it cleaned 4--
Yes 0 No
5. Observed condition of component pumped:
----J—Ijff-P---�;�----------
6, System Pumped By:
JDave TIn AA Mass IAD31Z
�-S S Name h::�rn b e r
eateson Enterprises, Inc_
-F,o-r- `npa—ny"-'--
7, ion where contents were disposed:
Signature of Hauler Date
Signature of Receiving F acHi (or attach facility receipt) Date
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