HomeMy WebLinkAbout- Septic Pumping Slip - 183 FOREST STREET 12/12/2018 2� Commonwealth of Massachusetts
_ . City/Town of NORTH ANDOVER MASSACHUSETTS
System Pumping
n Record Y p g d
Form 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.
A. Facility Information
Important:
When tiling out 1. System Location:
forms on the r T01NN` i f ii,f`I"[i r°'f 1➢rl'r�Ft;�
uter,use
orp
tiythetabkey Address -c ) `(JNf,
to move your
cursor-do not ---------- �_
- .___�..._
use the return
Citylrown -,--.-
State Zip Code
..�
key,
2. System Owner:
_,..r_.._ .__...�__.-...__.�..._._.-.._...
Name ..-- -
Address(if different tram locatian) �------
Cityrrown ___a„_ .—..�_._._w—_._
State Zip Code
l elephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: '-` =—... _...�
Gallons
3. Type of system: ❑ Cesspool(s) "'Septic Tank [] Tight-Tank
[� Other(describe):
4. Effluent Tee Filter present? [_9 A`Yes No If yes, was it cleaned? 0—f Yes ❑ No
5. Condition of System:
6. System Pumped By:
Vehicle License Number
company
7. Location where contents were disposed:
Signature of r-tauler pate ..—...-,.
http://www.riiass.gov/dep/water/approvals/t5forms.litm#Inspect
t5form4.doc-06/03
System Pumping Record•Page 1 of 1