HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 161 RALEIGH TAVERN LANE 8/19/2026 Commonwealth of Massachusetts Town of No*Andover
City/Town of► t— AUG 2 5 2026
System Pumping Record
Form 4 Health Department 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 15.351.
A. Facility Information
Important:When
filling out farms 1. System Location:
on the computer,
use only the tab J LL)
key to move your Address s
cursor-do not
use the return -L-2c," AV)00-14P
key. Cny/Town A
fate
2. System Owner: -ZiP Code
("o,
Name
Address(if different from location)
City/Town State Zip Co deEs. Pumping Record Telephone Number
-----------
1. Date of Pumping -sate 2. Quantity Pumped:
Gen,n
3. Component: 0 Cesspool(s) Septic Tank 0 Tight Tank n Grease Trap
El Other(describe):
4. Effluent Tee Filter present? El Yes 0 No If yes, was it cleaned? El Yes El No
5. Observed condition Of component Pumped:
6. Syst Pumped By:
N ZA Z/&/
Vehicle License Number
Company
7. Location where contents were disposed:
Cr
Sign tore of Hauler
Signature Or liecelving Facility(or attach—facility receipt—jj
Date
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System Pumping Record
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