HomeMy WebLinkAboutSeptic Pumping Slip - 72 SUGARCANE LANE 5/21/2018 Commonwealth of Massachusetts
F city/Town of NORTH ANDOVER, MASSACHUSETTS �a
r System Pumping Ret=ard
i 4 Form 4 p
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 1. System Location:
the tab key Address
forms on the /7
computer,use
only .._5 _..-.
to move your North Andover MA 01845
cursor.do not
use the return City/Town State Zip Cade
key.
2. System- caner:
es b
ame
Address(if different from location)� —"—
Telephone Number ---
B. Pumping Record
1. Date of Pumpingcta – � 2. Quantity Pumped: –�—
Gallons
3. Type of system: ❑ Cesspool(s) AlSeptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? 0 Yes to If yes,was it cleaned? ❑ Yes No
5. Condition of System)):
6. System Pu p By:
Vehicle License Number --��-
Wind River Environm
7. Location where cont is were�p sek�r
Signatur o"--a er pate -
http://www.mass,gov/dep/water/approvals/t5forms.htm#inspect
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