HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 316 RALEIGH TAVERN LANE 5/14/2026 Town of Willh Andover
Commonwealth of Massachusetts
}'` = City/Town of MAY 15 2026
S stern
Y P um ping Record
�— Form 4 aft DePartment
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 forn'r they use. The System Purnpincg Record must be submitted Io
the local Board of Health or other approvir)g authority within '14 drays from the pumping date In
accordance with 310 CMR 15 351
A. Facility Information _...___ ... BUILDING Front back side rear lef-t ri
F;
Important;When DECK: Ur'1deI'
Mling out forms 1 Systern Loc'c:Ition
on the computer,
use only the lab — - --- �.._- �
key to move your Address
cursor -do nol � MA
se the return —__
koy. .-,lade Zip Code
f :.-- 2. Systein Owner.
N
r
ame
L21 ILI I
-— --- -Address different rrorn location) -- --
MA
ty(Town E;lale Zip-c-o
elephone Number
B. Pumping Record
1. Date Of Pum m - _- -_._ _____.____-- 2
p 9 C>al. Quantity Pumped: -----------_-..
Gallons
3, Carraponent: cesspool(s)
(_ (7hr lank �..� Tight Tarrk 7_1 Grease Trap
_.� Other (describe) _ _ . .__.
4. Effluent Tee Filter present? ❑ `,'es o If yes, was it cleaned? ( ] Yes No
5. Observed condition of component p rnpryd:
C. stem E Wmped BY: _........
3
DaveTiney_ _.._— -Mass 1A,A95E fvf s 1A0317_
Name Vr~hlcle Lic�^nse Number
aresin Enferpnses Inc
Company
7. Location ere contents were disposed:
GLSD
Signalure of f-iauler Date - .----- — - ------ --- --
P
Signature of Receiving I acility (or ally h facility receipt)
fsformkdoc, 11f12 S stern Purn yin Record T;:
�'' ( 9 '7gEy 1 oI 1