HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 101 CRICKET LANE 10/5/2010 -C-N Commonwealth of Massachusetts t �
City/Town of NORTH ANDOVER MASSACH S
System Pumping Record r� T - 2010
Form 4
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. The st
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location: / � C
foefrms on the '
computer,use
�Url e -
only the tab key Address
to move your -
cursor-do not City/Town/Town P !
use the return y S e Zip Code
key. 2 System Owner-
VQ -
den d 1- .
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping `t 2. Quantity Pumped:
Datee Gallons
3. Type of system: ❑ Cesspool(s) „Septic Tank ❑ Tight Tank
❑ Other(describe): -
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. S stem Pum padBy:
Vila
Name Vehicle License Number
Company
7. Location ere contents were disposed:
ill pfd lict-
ISature of Hau r Date
http-.Ilwww.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03
System Pumping Record•Page 1 of 1
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