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Home My WebLink About- Septic Pumping Slip - 1044 JOHNSON STREET 12/12/2018 Commonwealth of Massachusetts = � City/Town of NORTH ANDOVER MASSACHUSETTS System Pumping Record �i . Form 4 _tJ 3 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; Wien filling out 1. System Location: forms on the computer,use only the tab key Address to move your CUfSQC-do flat ,_.,—_-...,.�,_..�_.__.�,_._-_. .w.�_� _ use the return GityCrown State Zip" C;acie key. 2. System Owner: Ij ..� Name Address(if different from State Lip Code _,�.�_a Telephone Number B. Pumping Record 1. Dale of Pumpingt' 2. Quantity Pumped: 'c` Gallons _ _ 3. Type of system: ❑ Cesspool(s) C]peptic Tank [ Tight Tank C] Other(describe): �- 4. Effluent Tee Filter present? ❑ Yes t A'"No If yes,was it cleaned? ❑ Yes ❑ No 5, Condition of System: 6. System Pumped By: ,. Name Vehicle License Number Gampany 7. Location where contents were disposed: 1 c Signature of Hauler --- - ---..—_-.--.----..�. Cate http://www,rnass.gov/dep/water/appr©vaIs/t5forms.htm#inspect t5form4.doc-06/03 System Pumping Record-Page 1 of 1