HomeMy WebLinkAboutSeptic Pumping Slip - 193 BERRY STREET 6/6/2018 Commonwealth of Massachusetts
_ Cit /Town of NORTH ANDOVER MASSACHUSETTS
11
S stem Pum in Record � i ,� �im �i �
W Y p g � �
Farm 4
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. I
A. Facility Information
Important:
When filling out 1. System Location:
forms the ,2"Z t�.�
computer,use _
01
only the tab key Address
to move your
cursor-do not _ w__.._... ___._.w...r..... _...__.....
use the return Cityrrown State Zip Code
key.
2. System owner:
Name
Address(if different from location) —
C,ityfrnwn State Zip Cade
Telephone Number
B. Pumping Record
1. Date of Pumping -pate - 2. Quantity Pumped: Gallons
1 Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe): _ _ ._..._.. _.m_.__ . .....__..._. _ _-- —. —
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned' ❑ Yes ❑ No
5. Condition of Si �� /
l C
5. System Pumped By:
Name v) �- c
Vehicle license Number
Company
7. Locations where contents were disposed:
.'5w7o _
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•08/03 System Purnping Record•Page 1 of 1