HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 173 RALEIGH TAVERN LANE 5/12/2026 Town Of Notth Commonwealth of Massachusetts
4ndover
City/Town of �Jo A*,6,cve)(' JUAI 15 2026
.. ......... System Pumping Record -lealth
Form 4 DePartMe/j
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 form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CIVIR 15351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab ............
key to move your Address
cursor-do not
use the return \J.tf......... ...................
key. City/Town State Zip Code
2. System Owner:
.......... .................. ----------------
Name
---------------------------- -—---------------------------------------------------------
Address(if different from location)
--—------------------------ ............
City/Town State Zip Code
Telephone Number'-
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) IdSeptic Tank ❑ Tight Tank F-1 Grease Trap
F-1 Other(describe): .......................--------------.................................. ................................. —-—---------------------
/I
4. Effluent Tee Filter present? M Yes No If yes, was it cleaned? ❑ Yes n No
5. Observed condition of component pumped:
&CO d-
6. System Pumped By:
C
7, C)
...........
-.alr�. ............ .
reme Vehicl
License Number
1 panDal
2
0 y
7. Location where contents were disposed:
-- ----------
-3 12-1 2,(P
Signature of Hauler Date
.................I I............. ......................... ....................... ....................... -...................----.........................................-....................
Signature of Receiving Facility(or attach facility receipt) Date
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