HomeMy WebLinkAboutSeptic Pumping Slip - 25 JERAD PLACE 11/27/2017 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSEIr71 ,10,
IJ-
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
Important,
When filling out System �;Rt I o r�y �-
forms on the 1 Sy
computer,use
's C/
only the tab key Add,
to move your North Andover
cursor-do not MA 01845
use the return Utyffown state
ZipCodekey.
2. System em
PAqy r:
b
`7
Name
Address Of different from location
)
CityFfown
State _Zip Code
Lo
Telephorfe Number
B. Pumping Record
1. Date of Pumping
ate r 2. Quantity Pum ped�
Gallons
3. Type of system: El Cesspool(s) Septic Tank E3 Tight Tank
F1 Other(describe):
4. Effluent Tee Filter present? El Yes No If yes,was it cleaned? Ej Yes ❑ No
5. Condition of syst9x.
6. System Pu p By:
Name
VehRe'67cense-Number
Wind R! er Environmental
Company
7. Location tents were disposed:
Q> � ,
-
Signature of i I 1,il
F He, r
Date
/de'jw't'rf. .....I
http://vmw.mass,gov/dep/wate1.)Ik:lr�li��v i,;f[5forms.htm#inspect
t5form4.doc-06103
System Pumping Record-Page 9 of I