HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 30 OLD CART WAY 7/17/2005 ae ,viev
Commonwealth of Massachusetts 52p12
City/Town of NORTH ANDOVER, MASSACHUSETTS ���- ti ANooveVk
System Pumping Record -VowNoFNOE N
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Form 4 NEALtH
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 46(
only the tab key ress
to move your v�e 6z A-
cursor-do not City�� State Zip Code
use the return
key. 2 System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
'7 -�'7 - DS— /SCT
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Lfl No 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:
Signature of Hauler Date
http://www.mass.gov/dep/water/approvalstt5forms.htm#inspect
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