HomeMy WebLinkAboutSeptic Pumping Slip - 1580 SALEM STREET 6/6/2018 Commonwealth of Massachusetts R E: C Cb Vz
City/Town of NORTH ANDOVER MASSACHUSETTS ("i '5 ?018
System Pumping Record
Form 4Ii Oi'w IIwi I u��kl'll� �v�ai�
�t 18LA -1 H DE'V'J"(CAS i CSV t
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:
forms on the
computer,use
only the tab key Address
to move your
cursor-do not ......_— �.._....__�...—_....--- —....._____.._.__
__.._ �__...-_..___—.-_..—_._...
use the return
Ciky/7awn Stake "Lip Code
key. 2. System Owner:
Name
r Address(if different from location)
CV1/fawn State Zip Code
Telephone Number
B. Pumping Record
1. date of Pumping -,.--____.._ 2. Quantity Pumped: Gallons
—
Date
3. Type of system: ❑ Cesspool(s) F9 Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
flame- Vehicle License Number
Company
7. Locationwherecontents were disposed:
Signature of Hauler Dake r
http:llwww.mass,gov/dep/water/approvals/t5forms.htm##inspect
t5form4.doc•06/03 System Purnping Record•Page 1 of 1