HomeMy WebLinkAboutSeptic Pumping Slip - 7 CANDLESTICK ROAD 6/6/2018 7
Commonwealth of Massachusetts
- City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Purnping Record must
be submitted to the local Board of Health or other approving authority.
r
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 Cityfrown State Zip Code
key. 2. Syst Owner:
U `e, _
Name
rn Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping —_...._— _._._ 2, Quantity Pumped: Gallons
l7ate
1 Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of,��stem:�
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
_6 X -D_........
—
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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