HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 30 OLD CART WAY 9/7/2021 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS v� �5101ti����,
System Pumping Record NORM�
Form 4 NOL NQEP
DEP has provided this form for use by local Boards of Health. The System Pumping Word 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
computer,use
only the tab key Address —I
to move your �U6 gat)dz—'� i{Q--
cursor-do not CitylTown State Zip Code
use the return
key. 2. System Owner:
Name
Address(if different from location)
CitylTown state Zip Code
7 9 a l
Telephone Number
B. Pumping Record
l
1. Date of Pumping Date 2. Quantity Pumped: 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:
c5�
6. System Pumped By:
G,0'24 / Sn
Name "��� Vehicle License Number
Company
7. Location where contents were disposed:
C� s
Signature of Hauler Date
hftp://www.mass.gov/dep/water/approvals/t5forms-htm#inspect
t5form4.doc•06103 System Pumping Record-Page 1 of 1