HomeMy WebLinkAboutSeptic Pumping Slip - 1451 OSGOOD STREET 9/11/2017 Commonwealth of Massachusetts
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 Recor ust
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important;
When filling out 1. System Location: t" S' `
forms on the
computer,use _..._ e' _�_w.. ....
only the tab key address --to move your j
cursor-do not - _-_ _.__
use the return City/Town State Zip Code
key. 2. System Owner:
QQ --—---------------
Name
' address(if different from location)
City/Town State Zip code
Telephone Number
B. Pumping Record
1. Date of Pumping2
Gate ----j�--- . Quantity Pumped: e3atlors �t
3. Type of system: ❑ Cesspool(s) FITSeptic Tank ❑ Tight Tank
❑ Other(describe): __-- - _—
4. Effluent Tee Filter present? ❑ Yes [1 No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
G
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler Date
i
http://www.mass.gov/dep/water/approvals forms.htm#inspect
j
t5form4.doc•06/03 System Pumping Record•Paget of 1