HomeMy WebLinkAbout- Septic Pumping Slip - 197 CAMPBELL ROAD 12/12/2018 m _ Commonwealth of Massachusetts
ry = City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Y p g
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 - , 1
Important:
lia
When ruing out 1. System Location: �
forms on the -- V
computer,use
only the tab key Address _.._. ---
to move your
cursor-do not
use the return City/Town State Zip Code
key.
2. System Owner:
Name _
_ Address(if different Born location)
Cktyrrown State
`telephone Number
B. Pumping Record
1. Date of In Pum
p g �riat�.. ..� �- 2- Quantity Pumped: ....—.._ __..._..—
Gallons
3. Type of system: ❑ Cesspool(s) L Septic Tank F] 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:
Name Vehicle License Number
7. Location where contents were disposed:
Signature of Hauler [date f
http://www.mass_gov/dep/water/approvals/t5forms.htm#inspect t
t5fami4.doc 08/03 System Pumping Record•Page 1 of 1