HomeMy WebLinkAboutSeptic Pumping Slip - 846 CHESTNUT STREET 12/13/2010 Commonwealth of Massachusetts b
City/Town of NORTH ANDOVER A A hi
System Pumping ecor
Form 4
DEP has provided this form for use by local Boards of Health. The S stow, m st
be submitted to the local Board of Health or other approving authors ' W
A. Facility Information
Important:
When filling out 1, System Location:
forms on the C
computer,use ` !� �l �' !"��..�� . .5 ,..
only the tab key Address
to move your
cursor-do not
use the return Cltyrl awn State Zip Code
keyl.I 2. System Owner:
Name
Address(if different from location)
City/Town — State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping `° 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) [] Septic Tank ❑ Tight Tank
❑ Other(describe): — -
4. Effluent Tee Filter present? 2/Yes ❑ No If yes, was it cleaned? El Yes ❑ No
5. Condition of System:
-- -o -.
& System Pumped By: .
Name Vehicle License Number
Company
7. Location where contents were disposed:
G' '.. >
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record-Page 1 of 1