HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 135 RALEIGH TAVERN LANE 4/16/2026 Town of NofthAndover
Commonwealth of Massachusetts
APR 1 2026
r a City/-f own of ----_
System Pumping Pecord
Form 4 HealthDepart ent
DE has provided this form for use by local Boards of Healtih. Other forms may he 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 forrn They use. The System, Rurnping Record must be subrnitted to
the local Board of Health or other approving suthority within 14 days fmn) the pumping date in
accordance with 310 CMR 15.351 — - ---___-- --_----- _ ---.__
HOUSE fron ha k side rc
r Ic>ft, riff t
A. aCl�l�y Information Bull_DING: front back side real Iefi right
lfnportaot;when DECK: udder
ruling out roan; 1. System Location:
on the cornpulor, *^
use only t17e tab _ . ..—_
key(o rnovEz your Address
culsor-do not ��,,..!!
u,e ffi e return -- --. __—_--- —_�t_.� _ --- MA
key. Ci(y(Town -—..__.--- SIaIEA-- ---------_--------
ey. Zip Code
rf_-- 2. System Own r:
TV
Name
in—rrn—�j"
Address fir different from location)
—__---- -.---- -- MA
dale
clephone Dumber
B, Pumping Record
1. Date of Pumping Dale� ---- 2, Quantity Pumped: �----
Galfons
3. Component: ❑ ces6pool(s) optic -i-ank
.) Tight Tank C�� Grease �hrap
Other (describe): _- -__--.__ ___._..
4. Effluent Tee Filter present? ❑ Yes J o f yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of cornponent p rnped
6. Sy It
Pumped By:
ave TIn _-__--------__--.---------.._..-___---_-_--_--_ Mass 1AA95E Mas 1AD31Z
ame Vehicle r_icense Number — ------_—.._—__--
akeson Enterprises, inc.
C f y - "
7. Loc (ion where ntents vvefe dispose t1
c�
LSD
S ig n i of kl a u l e r Dale _. -- -- ----------------
-
Signalure of ,ec.ewing acility (or attach (aciliry receipt) mete ---
t5forr)4.doc- 11112
System Pumping f�)ecord f',�r1e 1 0l 1