HomeMy WebLinkAbout- Septic Pumping Slip - 30 TANGLEWOOD LANE 12/12/2018 Commonwealth of Massachusetts
44 City/Town of NORTH ANDOVER MASSACHUSETTS
r System Pumping� pMng Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
i
be submitted to the local Board of Health or other ap
proving authority,
j Facility Information - —
Important.:
Mien filling out 1, System Location:
forms on the
�
computer,use .�(- /}�>Liel i�: (r.+��.,�"�� r��',only the tab key
Address —
-
to move your —
cursor-do not � ,� r
use the return city[rown ._,.—
key. State Zip Code
2. System Owner:
1 t 1< 'L. Cy-}erg !l) +ZL,_/"I_4
Name
19M
�' lion different from if location)
Address
_
State Lsp Cade
T`elephonc Number —_--
B. Pumping Record
1. Date of Pumping -_
Date — 2. Quantity Pumped:
Gallons
3. Type of system:YP Y .❑ Cesspool(s) [w�(''Septic Tank El Tight Tank
❑ Other(describe.):
4. Effluent Tee Filter present? ❑ Yes (J No If yes,was it cleaned? ❑
—
Yes ❑ No
5. Condition of System:
6, System Pumped By:
Name
Vehicle license Number
Company ..—_
7. Location where contents were disposed:
Signature of Hauler — ——
Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4-doc•06/03
System Pumping Record-Page 1 of 1