HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 93 RALEIGH TAVERN LANE 4/8/2025 Commonwealth of Massachusetts Town of'!'llh Andover
City/Town of
APR 14 System Pumping Record 2025
Form 4
'3�1' lth Dep,2rtr,1,('1)W
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: C��'on�,�)back side rea left ipht
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1 system Lo ation,
on the computer,
use only the tab 1�zt-'L �(-
key to move your A d'd" 9 s
cursor-do not MA
use the return
key. CityrTown State Zip Code
2. System Owner:
10 1
"Y'
r
-------...... .........
Narne
Address (If differentlocation}
MA
City/Town State C Z'op Code
1 11 Telephone N u m-b a r
B. Pumping Record
1, Date of Pumping 2, Quantity Pumped,
DateGallons
3, Component: ❑ Cesspool(s) Septic Tank Tight Tank [71 Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? Fj Yes
No If yes, was it cleaned? E] Yes F j No
5, Observed condition f component p mped:
...............
6. System Pumped By.
Dave TIney Mass IAA95E /f 0'2SS-1 AD 3"
Name er VehIcle License Nurn t
eateson Enter rises,
Company
7, tpn where contents were disposed,
GLSD
------...... --------
_ _ ❑ �_
_________
SIgnature of_
Hauler —---------- -D--a'-t e
7 Date
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