HomeMy WebLinkAboutSeptic Pumping Slip - 707 TURNPIKE STREET 6/6/2018 �r
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSA► HUS T
System Pumping Record iq
Form 4
TqW
DEI'has provided this form for use by local Boards of Health. The Syst t t ,
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 q.
cursor-do not
use the return City/Town State — Zip
key. 2. System Owner:
Name9- --- --------------------
Address(if different from location)
City/Town State Zip Code
Telephone Number -- -- —
B. Pumping Record ---
Am
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) elSeptic Tank ❑ Tight Tank
❑ Other(describe):
y
4. Effluent Tee Filter present? ❑ YesEl No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
q Zystem Pumped
11 7:k
ame Vehicle License Number
Company
7. LocatiopAvhere contents were disposed:
V/6
gnature of Hauler Date
http://www.mass.goWdep/water/approvals/t5forms,htm#inspect
t5fonn4.doc-06/03 System Pumping Record•Page 1 of 1
t