HomeMy WebLinkAbout- Septic Pumping Slip - 649 FOREST STREET 12/12/2018 Commonwealth of Massachusetts
= � City/Town of NORTH ANDOVER MA,SSACHUSETTS
System Pumping Y p g Record
Form 4
MP has provided this form for use by)oval 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
computer,use
only the tab key Address -- ---__�.
to move Your
cursor-o not A-AD
City/Town
use the return State _._ Zip Code
key.
2. System Owner:
Namo -._._—_ _.�_. �._ .....�
Address(if d"rfferea7t from location) - -- ----..—
CitylTown _ate-.,. -- .-_. — -�_
State 7..ip Code
__—__ _...__._-__
Telepttorre Number
B. Pumping Record
r, ,
1. Date of Pumping - — 2. Quantity Pumped.-
Date
Gallons
1 Type of system: ❑ Cesspool(s) ❑ Septic Tank
p ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [rN/a If yes, was it cleaned? ❑ Yes ❑ No
5- Condition
//of System:
6. System Pumped By:
Vehicle License Number
Company
7. Locationn, where contents were disposed:
Signature of Hauler _-._. .._._.. _.. �__---
Date
http://www.mass-gov/dep/water/appro'vals/t5forms.htm#inspect
t5form4.doc•06/03
System Pumping Record•Page 1 of 1