HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 30 OLD CART WAY 8/30/2022 Commonwealth of Massachusetts
City/Town of NORTH ANDOVERI MASSACHUSETTS
System Pumping Record
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 3 ®Id GA 2'f V 4-N
only the tab key Address
to move your A/✓d p v,g !'t �` /d' S
cursor-do not C��o State Zip Code Q
use the return itY
wn
key.
2. System Owner:
Name
a ccJ�
,ac,n Address(if different from location) oft �
City/Town State iP e
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? 2 Yes ❑ No If yes,was it cleaned? [!] Yes ❑ No
5. Condition of System: )
(S m d
6. System Pumped By:
G�r7�ry �C_
Named / Vehicle License Number
Company
7. Location where contents were disposed:
C�� S
-Signature of Hauler Date
http://www-mass.gov/dep/water/approvals/t5forms.htm#inspect
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