HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 30 OLD CART WAY 9/9/2016 vkECENEp
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS R Et
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System Pumping Record voWNof OePPA'T
=� Form 4 NEP
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. Facility Information
Important:
When filling out 1. System Location:
forms the c ,n i / /v�u
computer,
r,use �t��
only the tab key Address
to move your Nj G C \s d `P.
cursor-do not Cdy/Town State Zip Code
use the return
key.
ey. 2. Owner. J
Name
Address(if different from location)
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) Septic Tank ❑ Tight Tank
❑ Other(describe): ��ry
4. Effluent Tee Filter present? ❑ Yes LS o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
C�C 5'
Signature of Hauler Date
http://www.mass.gov/dep/water/approvalstt5forms.htm#inspect
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