HomeMy WebLinkAbout- Septic Pumping Slip - 125 SULLIVAN STREET 12/12/2018 _ Commonwealth of Massachusetts
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City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping 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,
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A. Facility information
Important:
When filling out 1. System Location:
forms on the
computer,use
only the tab key Address --.—
to move your
cursor-do not —____ _
-_
City/Town use the return �'/Town State Zip Cade
key.
2. System Owner:
Name ..
address(if different from location)
City/Town State Zip Cade
Telephone Number
—---_._..--
B. Pumping Record
1. [date of Pumping �._'
Date — 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
[J Other(describe):
4. Effluent Tee Filter present? ❑ Yes D-11�10 If yes, was it cleaned? EJ Yes E No
5. Condition of System:
6. Systern Pumped By:
Name Vehicle t.icense Nurnber
Company_._......
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7. Location where contents were disposed:
=. =5 '
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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