HomeMy WebLinkAboutSeptic Pumping Slip - 1634 SALEM STREET 9/11/2017 Commonwealth of Massachusetts
a City/Town of NORTH ANDOVER CHUSE' T
�.r System Pulping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping R d must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
PQ
When filling out 1. System Location:
forms on the
computer,use
only the tab key Address _—..__...
to move your r
cursor-do not —_......._.__. -
use the return City/Town State Zip Code
key.
2. System Owner:
Name
Address(if different frorn location)
City/Town Y Stale Zip Code
Telephone Number
B. Pumping Record
..: fir 4>
1. date of Pumping — 2. Quantity Pumped: J_..._..._... _
Date Gallons
3. Type of system-, n Cesspool(s) Septic Tank E] Tight Tank
❑ Other(describe): -....... __.
4. Effluent Tee Filter present? ❑ Yes [ o If yes,was it cleaned? ❑ Yes [ ] No
5. Condition of System:
w
6. System Pumped By.
Name Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler Date
http://www.rnass.gov/dep/water/approvals forms htm#tinspect
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