HomeMy WebLinkAbout- Septic Pumping Slip - 614 FOREST STREET 12/12/2018 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSACHUSETTS
System Pumping Y pang Record
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 filling out 1. System Location:
forms on the
computer,use a
only the tab key address �.. ..
to move your cursor-do not
City/t•own —._ — _
use the return State Zi d.—_.�
key. p Cade .—.`._.._
y 2. System Owner;
y
Narm
.
Telephone Number
B. Pumping Record
1. Date of Pumping r
2. (quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) El Se tic Tank
p El Tight Tank
[1 Other(describe): — —.--..—...—.._
4. Effluent Tee Filter present? ❑ Yes E No If yes,was it cleaned? ❑ Yes
Ej No
5. Condition of System:
B. System Pumped By:
Name
Vehicle License Number —
ompany
7. Location where contents were disposed:
Signature of Hauler —
Date
http://www.rnass,gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03
System Pumping Record•Page 1 of 1