HomeMy WebLinkAboutSeptic Pumping Slip - 178 STONECLEAVE ROAD 3/3/2016 Commonwealth of Massachusetts
City/Town of
- System Pumping o r
Form 4
h 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 e hum nng date in
accordance with 310 CMR 15.351,
A. Facility Information
Important: 1. System `TOWN OF NORTH ANDOVER,
h �' Yarn � �t :tA �rNT
When filling out Y
forms on the '""" G
Location:
computer,use " t
to move our o ✓_ _ l m
only the tab key Address c) U
cursor-do not City/Town State Zip Code
use the return
key. —2. System Owner:
VC.j—
Name
Address(if different from location)
------- ——— — — -- _...-- r
State _ Zip Code
City/Town
Telephone Number _
B. Pumping Record
t
1. Date of Pumping Date
---- 2. Quantity Pumped:
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ______---- �_,/—.-
-- ..---
4. Effluent Tee Filter present? E] Yes U No If yes, was it cleaned? ❑ Yes No
5. Condition of System:
6. System Pumped By:
-- - — I — Vehicle License Number
-- — —
Name /
-Company
7. Location where contents were disposed:
Signature of Hauler
Signature of Receiving Fa cility
Date
System Pumping Record•Page 1 of 1
t5form4.doc•03/06
Commonwealth of Massachusetts
((K'
City/Town of NORTH ANDOVER MASSACHUSET
TS
System Pumping Record
44`f Form 4
DEP has provided this form for use by local Boards of Health. The Sy Pumping Record must
be submitted to the local Board of Health or other approving auiffi6rif V?E"('�"E 1"V E U".
A. Facility Information proving tau—h6ri,'.t,(',,'_
"J
Important:
When filling out 1. System Location:
\1 'J
forms on the "V1 ("
computer,use 0
only the tab key Address,
to move your
cursor-do not
use the return y/Town State Zip Code
key.
2. System Owner:
a
Name
�A
Address(if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping L211 C-,-) C-�-�)
Date 2. Quantity Pumped: Gallons
3, Type of system: ❑ Cesspool(s) $'Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present?yYes A No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
CN,
6. System Pumped By:
Name 14 (;,- 6,
Vehicle License Number
Company
7. Location where contents were disposed:
�4
, e"
-S7ignaturiFof Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms,htm#inspect
t5form4.doc-06/03 System Pumping Record-Page 1 of 1