HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 30 OLD CART WAY 4/29/2009 R�oE'vEo
Cor>rnonwealth of Massachusetts ��` 2 5 2022
City/Town of NORTH ANDOVER, SPAR metANIT a
MASSACHUSET��of�co
System Pumping Record HEAT"o
w
-� 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 on the
computer,use only the tab key Address
to move your
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 Da 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:
6. System Pumped By:
/ �cY C- v'l c c
Name Vehicle License Number
Company
7. Location where contents were disposed:
C,C s
Signature of Hauler Date
http://www-mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06103 System Pumping Record.Page 1 of 1