HomeMy WebLinkAbout- Septic Pumping Slip - 1925 SALEM STREET 12/12/2018 _ Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSACHUSETTS
1
System Pumping Record
Form 4 i
1
f
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. Facilifrinformation
-
Important:
Mien fining out I. System Location:
forms on the
computer,use
only the tab key Address
to move your
cursor-do not
use the return City/Town
State Lip Code
key.
2. System Owner:
Name _ ._...... __..
_ _._.. — „.. _ —._ -_
A dress(if different from tacation) __� ._._, i
. i
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. date of Pumping Date — 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Q Septic Tank ❑ Tight Tank
[� Other(describe)-
4. Effluent Tee Filter present? [A Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number 7. Location where contents were disposed: j
Signature of t lauler pate —
http:l/www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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t6form4.doc•06/03 System Pumping Record•Page 1 of 1