HomeMy WebLinkAboutSeptic Pumping Slip - 31 BRIDGES LANE 11/27/2017 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSACHUSETTS
System Pumping Record
Form 4
DBP has provided this form for use by focal Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility information
Important:
When filling out I. System Loc& on:
farms the a
computer,use ( (/ bV
only the tab key Address to move your North Andover
cursor-do not MA 01845
use the return City'T"own State
Zip Code
key, 2 Sys m Owner:
rte 5t
Name
Address(if different from location)
CitylTown Stat ode
f�
Telephone Number
B. Pumping Record
1. Date of Pumping
P 9 Dat 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe): — —
a. Effluent Tee Filter present? ❑ Yes 14'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of S em:
6. Syste� ed By-
Nam //lrr 7 2--
Vehicle License Number
iv
7.
Locat�lR}s were disposed:
, l
Signature of Hauler tate
hftp://www,mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page i of t