HomeMy WebLinkAboutSeptic Pumping Slip - 181 JOHNNY CAKE STREET 9/11/2017 Commonwealth of Massachusetts
h City/Town of NORTH ANDOVER, MASSACHUSETTS
IL 1
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.
A. Facility Information VIC
Important:
w p n filling out 1. System Location: PN
forms to the
computer,use ...__.,C.� �.�./)_GLYt'•L �-t��.�
only the tab key Address
to move your
cursor-do not
use the return Cityrrown State Zip Code
key.
_._.._. 2. SysKarn e:r Owner:/t'!_ -____ 1� _ ...--_...._ _... _... ___...._..__. .. __ -VQ
!�. ,rJ,�t �
Name U
Address(if different from location) _...._
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping - 2. QuantityPumped:ed: _..._..--
DateGallons
3. Type of system: ❑ Cesspool(s) F�Septic Tank [ ] `Fight Tank
L� other(describe):
4. Effluent Tee Filter present? n Yes L4'-'N'o If yes, was it cleaned? (_,] Yes n No
5. Condition of System:
6, Sys em Pumped By- 1
7/ ,
Name Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler pate
http://www,mass.gov/dep/water/appr-ovaIsaforms.litrnf#inspect
l
t5form4.doc•06103 System Pumping Record•Page 1 of 1