HomeMy WebLinkAbout- Septic Pumping Slip - 1060 SALEM STREET 12/12/2018 Commonwealth of Massachusetts
7 City/Town of NORTH ANIDOVER 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,/
i
A. Facility Information
1
Important:
Mien filling out 1. System Location:
forms on the
computer,use
only the tab key Address
to move your
cursor-da not �'� ' � >LC 6.`�.�4-aZ_.,
_.—
—_ ._- _
use the return City/Town
State Zip Code —�
key.
2. System Owner:
Name
Address(if different�.--. location)
- ,� from lo<;aticn) -- _-----_.----___—
_6;f __. _...._...—...�.�
Telephone Number
B. Pumping Record
1, bate of Pumping e-)--,r , ' _
Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ❑t Septic Tank ❑ Tight Tank
Other(describe):
d. Effluent Tee Filter present? ❑ Yes Nop If yes,was it cleaned? C] Yes ❑ No
5. Condition of System:
6. System Pumped By:
Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler _—
Date
hftp://www.mass,gov/dep/water/appro'vals/t5fofms.htm#inspect
t5form4.doc-06103
System Purnping Record•Page 1 of 1
