HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 301 RALEIGH TAVERN LANE 8/31/2026 Commonwealth of Massachusetts 7bwn of Nortt,AndOver
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❑� ` r City/Town of _ __ 202
System Pumping Record
❑�'�� ❑ Form 4 Health
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 CMR 15.351. m'
HOUSE: fron , side rear Ief right
A. Facility Info rmatioii BUILDING: front back side rear C�f"'f' right
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key. Cily/lawn State Zip Code
2, Sy r Owner;
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C(ly(1 own State Zip Code
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elephone Number
B. Pumping Record
1. Date of Pumping ciat -.-- ---------- 2. Quantity Pumped:
_--
3. Component: ❑ Cesspool(s) optic Tank ❑ Tight Tank ❑ Grease Trap
(� Other (describe):
4. Effluent Tee Filter present? ❑ Yes "'"NO If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of con-iponent Ur feed;
6. System Pumped By:
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Dave Tined - ..._.---.--------_._._...._____.___._--_ Mass 1AA95E Mass 1AD31Z
Name Vehicle License: umber
Bate n Enterprises, Inc.
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7. Location where co � di posed:
ULSD
Signature of Hauler pale
signature of Receiviiig'Faality (or attach facility receipt} Date
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