HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 82 RALEIGH TAVERN LANE 7/24/2025 Commonwealth of Massachusetts r°wn Of iVa rth doVer
City/Town of AUG
°1 stet
y ping Record
Form 4
"ealth De
DEP has prrwideC'd (his fr;;>rr7� fair use by focal �or�srr�ds of lic"'lth Other forms may be u3ed' but C,t
information rnust be substanlially the sarne rss Ih<rt provided ner(,- Pefrc)re r,js,inq This form check %A/ilh yot
local Board of Health to determine the forrn fhray use. 1-he System Pumping Record rr'tt.lsl he submitted trr
the local Board of Health or other approving <Wthority within '14 days from the purnpirrcd date In
accordance with 310 CMR 15.351. ------
_—_.---- ___._.—_ _._.. t-OUSE: fror7 hack, side i'es S right
A. Facility Information RUILDINGJ front r)arck side rear lefl riph[
Important;When DECK., rrY1do.
filling out forms 1. Systern Location:
un the computer,
use only tho tat) G .__/ F, / f _.. fl ✓"�...._..t !'►
key to move your Addross
Cursor-do not
use the return — `--..— MA.---�___.—._�____w_.__
C t CI own __...._ ...---.__.._ —_.____ -------
key. Y Slale Zip Cade
2. SysterrlOwner
All
urvn �%
Address (If different from localion)
MA
Cil (To
Y :da
wn le Zip Code
To-le phone Nurr'il:rer
B. PLIMpincg Retard /
1. Date of Pumping [-aai s- � ._ ._.. .- 2. (quantity Pumped, xr
Gallons
3, Component: Q cesspool(s) Septic 'Tank Tight Tank ❑ Grease Trap
[_) Other (describe): _____
4, Effluent Tee Filter present? (.-_� Yes [fJ No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
6. System Pt nnped By.
Dave TIney Mass IAAr)SE ass IA031 .
PJarTt r3 Vr_YI Ie, 1.1cens,o tJum r
�af�son �nf�r�rls�s,_Inr._
Cornpany
7. Location whore contents we-cc disposed,
VLSI
Sign alure of Hauler (,ale
Slgnalure of deceiving futility (or attach facility feccipi) Dale
Worm4.doc• 11112 System Pumping Rlec.,ord Parr; t c'if 1