HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 136 RALEIGH TAVERN LANE 6/9/2026 Commonwealth of Massachusetts Town Of NOO Andover
City/Town of
S (stem Pumping Record JUN 15 2026
Form 4
Health D
DEP has provided this form for use by local Boards of Health. Other forms may be usedVA07ient
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 CMR 15.351.
rig t
HOUSE: front'rbac
A. Facility Information BUILDING: front �"side rear left "rig"
DECK: under
Important;When
filling out forms 1. System Location:
on the computer,
use only the tab . ),3 � P,�t�,��t ire)
key to move your Address I
cursor-do not A/
use the return MA
key. City[Town State Zip Code
2. Sys,m Owner:
Name
Address(if different from location)
MA
City State ZI Code
I (�- � 4--
Telephone Number
B. Pumping Record
1. Date of Pumping bate 2. Quantity Pumped*
- Gallons
3. Component: M Cesspool(s) [f'Septic Tank F-1 Tight Tank F-1 Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? Fj Yes 0 If yes, was it cleaned? M Yes � No
5, Observed condition of component pumped:
6. stem Bumped By:
De Mass 1AA95E Mass IAD31Z
Name Vehicle License Nu ber
Bateson Enterprises,
Company
7 Location her 7�contents vyere disposed:
§:j—gCai-u-r-e—of Hauler Y Date
-Signature of Recei\A-ng Facility(or attach-facility 7receipt] ------
t5form4.doc-11/12 System Pumping Record-Page 1 of 1