HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 22 RALEIGH TAVERN LANE 7/17/2026 I'J"n 01 North Andover
Commonwealth of Massachusetts JUL 2 7 2026
City/Town of
System Pumping Record Health DepartMeilt
Forma
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 CM R 15.351. 't
HOUSE- aro , @ck side re(r
A. Facility Information BUILDING: front back side rear eft
right
Important:When DECK: under
filling out forms 1. S7 L or 0a,
on the computer,
use only the tab
key to move your Address
cursor-do not MA
use the return City/Town State Zip Code
key.
fly u2. Systefn Owner:
llb )Ae—ArC4 0
Name
Address(if different from location)
MA
7C71ty—[1'own State--�Go Code
Telephone Number
B. Pumping Record
Date of Pumping 1 pate 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ptic Tank 7 Tight Tank ❑ Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? El Yes No If yes, was it cleaned? E Yes ❑ No
5. Observed condition of component Vumped.*
6, System Ptimped By:
Dave Tiney Mass lAA95E Mas"s 1AD31Z
System
Vehicle License Number
Bate n Enterprises, Inc.
any
01P any
0 'a dIs
T ocation whe nt nts re di osed:
LS
tGLSD
Signature of Hauler Date
Signature of Receiving"Facility—(or attach_-ac—h--fa—cl-li—ty--r--e-ce-i-p-t)---, Date
t5forrn4.doc- 11/12 System Pumping Record -Page I of 1
o