HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 30 OLD CART WAY 7/17/2014 BECEIVED
Commonwealth of Massachusetts �U` 252022
City/Town of NORTH ANDOVER, MASSACHUSETTS aRTHaNDci�R
System Pumping Record SOH�L HDEIPP""V N
-� Form 4
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 to the �Q
computer,use
only the tab key Address —�
to move your ,i , 1
cursor-do not City/Town State Zip Code
use the return
key.
2. System Owner:
n
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date- 7 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: n
6. System Pumped By:
Name a—� Vehicle License Number
Company
7. Location where contents were disposed:
C,Cs �
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc-06/03 System Pumping Record•Page 1 of 1