HomeMy WebLinkAbout- Septic Pumping Slip - 1075 SALEM STREET 12/12/2018 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSACHUSETTS
System Pumping Record
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Form 4
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DEP has provided this form for use by focal 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 r
computer,use % /
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only the tab key Address
to move your
cursor-do not /�'` l "`
/Town —.___ _... .. _.._
use the return Ci h' _.__.... �._-...._._._.�_._.._
State
key. Zip Code
2. System Owner:
Name
fferent from IocaUon) —.—..
CilyCiawn State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 'oatE 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) [J Septic Tank ❑ Tight Tank
[] Other(describe):
4. Effluent Tee Filter present? [..� Yes If yes,was it cleaned? ❑ Yes 0 No
5. Condition of System:
6. System Pumped By:
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1
aC.—
Me Vehicle License Number
Company
1
7. Location where contents were disposed: i
I
Signature Of Hauler Elate
http://www.mass.gov/dep/water/approvals/t5forms.htm##inspect i
t5form4_doc-06/03
System Pumping Record•Page 1 of 1