HomeMy WebLinkAboutSeptic Pumping Slip - 255 JOHNSON STREET 2/20/2018 Commonwealth of Massachusetts
''fiHM
City/Town of NORTH ANDOVER
MASSACHUSETTS
:1
System Pumping Record NAB
Form 4
P Pw�t~t �
DEP has provided this form for use by local Boards of Health. The System Pumpin ecord must
be submitted to the local Board of Health or other approving authority.
A. Facility information
Important:
When tilling out 'I. System Location:
farms the
computer,use °'�' � S
only the tab key address
to move your
cursor-do not _.. __..—....__
use the return ityn-own ;Mate Zip Code
key.
2. Systern Owner:
Name
&-
A Address('if different frorn location),�, -
Cityffown State Zip code
Tel�'phone Number
B. Pumping Record
1. Date of Purrt.ince IS-"
p nate _—_....... 2. Quantity Ptiiriped: _..�.._—......_`_
Gallons
3. Type of system: ❑ Cesspool(s) -., Septic Tank ❑ Tight Tank
❑ Other(describe).-
4.
describe):4. Effluent Tee Filter present? ❑ Yes _._ No If yes, was it cleaned? ❑ Yes F] No
5. Condition of System:
6. System Pumped By:
aff1e vehicle license Number
Company
7, location where contents were disposed:
;7igna urc of Hauler Cate
http://www,riiass.gov/dep/water/approvals ,forms.htrn#finspect
t5form4.doc•06/03 System Pumping Record Pane 1 of 1