HomeMy WebLinkAbout- Septic Pumping Slip - 265 GRANVILLE LANE 12/12/2018 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MA.SSACHUSETTS
- stern S Pumping
Y Record
Form 4
M
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 I. System Location:
forms an the ` r,
computer,
y puter,use
he
only lab ke �-
to move your _.._
cursor-do not hwl:> tom' ` C- x
City/Town �.,. _
use the return _.-
key. State Zip Code
y 2. System Owner:
Narne
Address{if different from locatior7)
City/fown
Stale lip Cade
felephone Number
B. Pumping Record
1. Gate of Pumping2. uantifiy pumped: 5~
Galtons
3. Type of system: ❑ Cesspaol(s} TD. Septic Tank ❑ Tight Tank
Other(describe):
4. Effluent Tee Filter present? [_) Yes (i%)No If yes, was it cleaned?
❑ Yes ❑ No
5. Condition of System:
6• System Purnped By:
Vehicle License Number
Company J
7_ Location where contents were disposed:
Signature of Hauler ___ r
Date
http://www.mass,gov/dep/water/appr6vals/t5forms.htm#inspect
t5form4.dac-06/03 Page 1 of 1
System Pumping record