HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 286 RALEIGH TAVERN LANE 6/15/2026 Commonwealth of Massachusetts Town Of* h AndoVer
City/Town of
System Pumping Record JUL 2026
Form 4 Health
DEP has provided this form for use by local Boards of Health. Other forms mp@pft
information must be substantially the same as that provided here. Before using this form, lawith 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 (j�7sicle re I
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. Syst m Locati
6y
6X,
on the computer, -T
use only the tab ❑
(A ❑
N1,0k,
key to move your Ad kress I
cursor-do not MA
use the return
key. Cityfrown State Zip Code
2. System Owner:
Name
IMP X"
Address(if different from location)
MA
CityfTown State i ode
-Telephone Number
B. Pumping Record
❑~
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: F-1 Cesspool(s) E2/Septic Tank El Tight Tank M Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? D Yes No If yes, was it cleaned? M Yes ❑ No
5. Observed condition of component pumped,
6 Sy tem Pumped By:
Da Tin Mass 1AA95E ass 1AD31Z
Name Vehicle License Numb r
Bateson Enterprises, Inc.
ompany
7. Lo v��rents were disposed:
catio
LS
Signature of Hauler Date
-Signature of
t5form4.doc-11/12 System Pumping Record-Page I of I
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