HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 317 RALEIGH TAVERN LANE 9/24/2025 4f`� Commonwealth of Massachusetts 'Own pfNprthndover
City/Town=f� �
v r� y/Town of
- System Pumping Record SEP 2 9 2025
Form 4
DEB has provided this form for use by local Boards of Heal H ftf�'r� be used, but the
information must be substantivally the same as that provided here. Be or Mi erft, check with y
local Board of Health to determine the form they use. The System Bumping Record must be submittec
the local Board of Health or other approving authority within '14 days from the pumping date in
accordance with 310 CMR 15.351 — ___--
f NQU=,L front b ac side rear lef
A,. Facility Information BUI LID IN0:(—+r�on1--'5ack side rear lef
r DECK: under
Important: When
filling out forms 1. System l_oC atlon
on the cornputer, a t �
use only the tab
key to rnove your Addr s C
cursor-do not y 6f\ MA
use the return
key. Ci! f-fown -- a..�-�'it"��te; Zip Code
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� 1 2. Sy tam O er�.
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Name
�d
—
-r --._.._ __ ____________..-----
-`�- Address (fF di(ierenl from locatio n)
MA
city(Town state Zip code - ---
TrIe phone Number
E3. Pumping Record
1 Date of Bumping Date — -- --- 2. Quantity Pumped:
t
3. Component: ❑ Cesspool(s) (Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe)
Effluent Tee Filter present? es No If yes, was it cleaned? es ❑ Na
5. Obser-ved condition of component primped:
�-,gar_ _ _____ _______ ______ _____ __ ______.
w"jd�„•
6 Sys T limped By a�
D, e TIney Mass 1AA95E ass 1AD31Z
�lamc V e h I c I e Licenses Numbor
Bateson Enterprises, Inc. "
Company
/ L Cr�t1C9f9 Wtle( ac)t r1tS WG'
Signaturo of f kauler Date
Signature of rkeceiving�f=ac.ility (or attach facility receif:�t) Date
t5forrn4.doc• 11112 Systen)Purnping Record •