HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 34 RALEIGH TAVERN LANE 7/31/2025 TaWn °f North
Commonwealth of Massachusetts q,�daVr
r
City/7 own of AUG------------- 2025
System Pumping Record
��,�.:�14•'�^ Form 4 `'�a��t�I
spa �
(7(f f hasfarrwide�d thus form, for L,sr> by local f3carards of Film-1l(h. Other forms may be, used, but Ili
Information must be substantially the sarne as fhal provided here 9e.fore using This form, chick will) your
loCal Board of Health to determine the for Ihr-�y use. They System Purnping Record rnt.lsl be submitle,d to
the local Board of Health or other approving aulhorl(y within '14 days iron-) the pumping dafein
accordance with 310 CMR 15,351
A. tC7USE front backside„
Facility information
Ie�f �;1i,1 •,,
BUILDING. front back side rear left ri;r i
Importan(: W)on DECK: unCier
(ltlmt(j out iorrns 1 Sy >lem ovation_
on the c;ornpuler, '"'� C (` .q /q 1_4u e only the ab
key to nibvi3 your A rt
cursor -do not /('� MA ty �'5
use I h e, r e I u r r, ---=--- �'"=----------_-- ------ --- ------ ----- �� --------
key. cityffown �e Zip Code
2. System Owner
-
-
i —
f�ftrh Address (II dirfereol frorn location)
MA
_ _-_---------- - --._. -- _ -- - -- - — -- - ---- -------—
CllyfTown SIaIe r Zi Code
Telephone Number
E3, Purnping Record ----
1. Cate of Pumping ,.2. Quantity Pumped: Gallons - ---
oalP,
3. Cornpooent: Cesspool(s) Z— stic -rank [_ ] Fight Tank Grease Trap
M O(her (describe) - -- . -- -- -
4. Effluent Tee f-ilter present-) FJ} Yes (_) No If yes, w�)s it cleaned-) ?�Yes ❑ rio
3. Observed concli(ion of cor-npone n purnp�d
6 , ystern P mped By:
3ve Tine Mas IAA95E Mat' 1AD31Z/
__ __.____y_ .__.-- _._. .___. . __ __. .___ _ .__._.----
Ian)o Vehicle License Number
Faso nlpvisos, Inc
Cornpany
7. Lca(iori where con(enls we(e disposed:
Gl_SC)
._ ------
Sign-
ture of Hauler _.
Dale
signature of Receiving Facilily (or aflract) facility f ceipi) 0a,Ie
Norrn4.doc� 11112. System,Pumping Record Pagel of 1