HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 75 SHERWOOD DRIVE 10/3/2019 Commonwealth of Massachusetts p7CEIVE,D
City/Town of w 0 3
SYstsm PUMpeng Record -TOM OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used but
information must be substantially the same as that provided here. Before using thls
Pumping Record form, checled must be submitte your
with
local Board of Health to determine the form they use.The System Pum
the local Board of Health or other approving authority. d to
Important:
When filling out' 1_ System Location:
forms on the r'�1
computer,use
only the tab key Address 7�^ S �i-✓UO C� i� ;"
to move- our
cursor-do not A//L' . n /a4'.-
use the return City/Town YYi _
key. state ZIP Code 2. System Owner:
tV� Name
&RE
Address(if different
from i�cationj
CitylTown
State ZIP Code
Telephone Number
B. Pumpin�
1. Date of Pumping /sucr
Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank
❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes E No If yes, was it cleaned?
❑ yes ❑ No
5. Condition of System: a.
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
C�Pr�•�
oignamn:or Hauler Date
t5form4.doc•06/03
System Pumping Record•Page 1 of 1