HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 285 RALEIGH TAVERN LANE 6/15/2026 Commonwealth of Massachusetts Town of A10dh AnUover
City/Town of
System Pumping Record JUL - 6 2026
Form 4
lleggapp
DEP has provided this form for use by local Boards of Health. Other for IM
information must be substantially the same as that provided here. Before using this f 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.
HOUSE: front back e rear�Ieft ght
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Locatio
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return MA
key. City/Town State Zip Code
2. System Owner: Yin
rv�A
Name
town
Address(if different from location)
MA
City/Town Zip Code
-Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) tic Tank 7 Tight Tank 7 Grease Trap
[] Other(describe):
4. Effluent Tee Filter present? [I Yes No If yes, was it cleaned? M Yes F] No
5. Observed condition of componen pum
�_47/"'yrn,(
6. Sys m Pum d By:
D e Tine Mass 1AA95V Mass I AD31Z
me Vehicle Licens umber
son Ej* r rises, Inc.Ka.te ,., �r_p�ri S
tent were dispc�sed_,,,
7. L catio whey tent were disposed:,,
LSD
P_
g�iture of I Hauler Date
Signature of Receiving'Facility(or aEtach facility receipt) Date
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