HomeMy WebLinkAboutSeptic Pumping Slip - 420 WINTHROP AVENUE 9/30/2016 a f
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Commonwealth of Massachusetts 1
- City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority. RECEIVED1
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1
A. Facility Information J AN 0 A 2 fl .
Important: 1
When filling out 1. System Location: TOWN OFF NORTH H ANt OVE
forms on the ) HEAUH DEPAUMENT
computer,use
only the tab key Abdress
to move your
cursor-do not —use the return Cityrrown State Zip Code
key. 2. System Owner'
- _-
Name
Address(if different from location)
Ciry/Town State Zip Code
Telephone Number
f
B. Plumping Record
1. Date of Pumping ate Quantity Pumped: Gallons--------
3. Type of system: ❑ Cesspool(s) peptic Tank ❑ Tight Tank
❑ Other(describe): --- —
4. Effluent Tee Filter present? ❑ Yes [ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name -- .__ Vehicle License Number
Company t
7. Location where contents were disposed:
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