HomeMy WebLinkAbout- Septic Pumping Slip - 1160 SALEM STREET 12/12/2018 _ Commonwealth of Massachusetts
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.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
„x
computer,useonly the tab key
to move your
cursor-do not
use City/Town
key.
2. System Owner:
Name
Address(if different frorn location)
_ i-....
ate
Zi Cade
Telephone Number
B. Pumping Record
17
•1. Date of Pumping pates— --...—,- 2 Quantity Pumped: G�`
Gallons
3. Type of system: ❑ Cesspool(s) []'Septic Tank ❑ Tight Tank
❑ Other(describe);
4. Effluent Tee Filter present? [d J'Yes ❑ No If yes,was it cfeaned? [fir Yes ❑ No
5. Condition of System:
6, System Pumped By:
Name Vehicle License Number__._.__
Company
7. Location where contents were disposed:
_v
c
(,Y
Signature � 7 )
of Hauler _Date
t — --
htfp://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 �
System Purnping Record•Page 1 of 1