HomeMy WebLinkAboutSeptic Pumping Slip - 102 SUGARCANE LANE 7/5/2018 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSACHUSETTS
System PumpingRecord
tti Form 4
DBP 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.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the +� —I
computer.use O C !
only the tab key Address
to move your North Andover MA 01845
cursor-do not CII (Town
use the return y State Zip Code
key. 2. System Owner: d
Name
Address(if different from location) -
CityiTown Slate
Telephone Number
B. Pumping Record
1. Date of Pumping ` 72. Quantity Pumped: � aU
Date Gallons
3. Type of system: ❑ Cesspool(s) [X Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No if yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By: C `
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
Signature of Hauler Da I r,
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect �¢
E5form4.doc-06103 �
System Pumping Record•Page i of t