HomeMy WebLinkAboutSeptic Pumping Slip - 1299 SALEM STREET 6/6/2018 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS �°���� 10 '5
System Pumping Record
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.
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A. Facility Information r
i
Important:
When falling out 1. system Location: /
forms on the 9'� �f c
computer,usel�t
only the tab key Address
to move your
cursor-do not ----._____._ _._.........
use the return City/Town State Zip Code
key.
2. System Owner
Name _........_._
Address(if different from location)
City/Town State Zip Code
Telephone Number
B.. Pumping Record
1. Date of Pumping mate Gallons 2. Quantity Pumped:
3. Type of system: ❑ Cesspool(s) _ Septic Tank ❑ Tight Tank
❑ Other(describe): -- ------------- ._____
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? Ej Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
c.
Signature of Hauler - date
http://www.mass,gov/dep/water/approvaIs/t5forms.htm#inspect
t5form4.doc•06103 System Pumping Record-Page 1 of 1