HomeMy WebLinkAboutSeptic Pumping Slip - 25 GILMAN LANE 6/6/2018 �Iffr
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
- Y g
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must J
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 cityrrown State Zip Code
key.
Z System Owner:
Name —
i
Address(if different from location)
City(Town State Zip Code
Telephone Number
B. Pumping Record
1. Gate of Pumping 3—le .__.`}.__. _ 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) D`S�eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? E] Yes [+`No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of S„ystem:
6. System Pumped By:
Name Vehicle License Number
-_......._................_.___...____-_----...__.-_-----
Company
7. Location where contents were disposed:
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htrn##inspect
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