HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 37 SCOTT CIRCLE 1/10/2022 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 n
be submitted to the local Board of Health or other approving authority.
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A. Facility Information
Important:
When filling out 1. System Location:
forms on the �c0—�' c!�
computer,use J � �
only the tab key Address /
to move your y,(a :ti 4 6 ✓c—iL /J1
cursor-do not
use the return City/Town State Zip Code
key. 2 System Owner:
VC] RP_4�e97.,4 _Py
Nam
&Al Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date r 2. Quantity Pumped. Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ErNo If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
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6. System Pumped By:
GI HR { St'/Z1 i CAL
Name ! Vehicle License Number
Company
7. Location where contents were disposed:
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Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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