HomeMy WebLinkAbout- Septic Pumping Slip - 31 BRADFORD STREET 12/12/2018 Commonwealth of Massachusetts
= . City/Town of NORTH ANDOVER MA.SSACHUSETTS
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.
A. Facility Information
Important: -
When filling out 1. System Location:
forms on the
computer,use y°3rl A
/ a.' c�
only the tab key Address
to move your
cursor-do not
use the return CitylTown --key. r — — _—.
>tate Zip code
..�.-_
2. System Owner:
Name
Address(if different from location)
_...—
S#ate
Telephone Number
B. Pumping Record
1. Date of Pumping — -- — 2. Quantity Pumped:Date
Gallons
3. Type of system: ❑ Cesspool(s) [.'..Septic Tank ❑ Tight Tanis
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? J Yes ❑ No
5. Condition of System:
6. System Pumped By-
Name — —
Vehicle License Number
Company _-_-
7. Locations-where contents were disposed:
12
_ � - _ >
Signature of Hauler —__..`_ Date.
http://www.mass,gov/dep/water/approvals/t5forms.YItrn#inspect
t
t5forrn4,doc•06/03
System Pumping Record•Page 1 of 1