HomeMy WebLinkAbout- Septic Pumping Slip - 53 SPRING HILL ROAD 12/12/2018 Commonwealth of Massachusetts
-- City/Town of NORTH ANDOVER MASSACHUSETTS
System Pumping Y p ng 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: i
When filling out 1. System Location:., 1,
forms on the
cornpuler,use a/(" f t
-- _ —
only the tab key Address
to move your }
cursor-do not .,�;,
ri Ci
ethe return �' �own
key.
2. System Owner;
Name
E ZA' 11,
Address(if different from location)
Cityfl•own
-..
Lip Code
B. Pumping Record -- -
1. Gate of Pumping Date r
_._ 2 Quantity Pumped: f,allans—_.--.____ —
3. Type of system- [� Cesspool(s)
[9''Septic Tank ❑ Tight Tank
J Other(describe);
4. Effluent Tee Filter present? W Yes ❑ No If yes, was it cleaned? [} des
[J No
5. Condition of/fSystem:
F. System Pumped By:
Name —u Ti
Vehicle License Number
7. Location where contents were disposed:
-- f _.Y✓ _„_.-- c icy
Signature of Hauler — .._,.___- �Datete
. _—
http:llwww.mass.gov/dep/water/approvals/t5forms.htm#inspect J
t5form4.doc•06/03
System Pumping Record-Page 1 of 1