Loading...
HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 271 BARKER STREET 10/26/2022 J_ Y 4 Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETTS 6tioti1 System Pumping Record �Z ti 0,01 -� Form 4 OAF Np, P�M�N� DEP has provided this form for use by local Boards of Health. The System Pu IA� Od 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 7 computer,use © K ---- -- only the tab key Address to move your OQ d ,(kNd� a4,f-L Y'm g s cursor-do not City/Town 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 1. Date of Pumping q _ 2. Quantity Pumped: Date Gallonss� 3. Type of system: ❑ Cesspool(s) E35eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes [:a-"N'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: 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 Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETT4v.` System Pumping Record CLI6 Form 4 BAN�M�N� DEP has provided this form for use by local Boards of Health. The System Pump't��r rust be submitted to the local Board of Health or other approving authority. 10 A. Facility Information Important: When filling out 1. System Location: forms onthe y7 computer, r,use only the tab key Address to move your , . cursor-do not City'/To State Zip Code use the return key. 2 System Owner: Name Address(if different from location) City/Tovm State Zip Code Telephone Number B. Pumping Record 2 Quantity Pumped: ! $o O . 1. Date of Pumping Date p Gallons 3. Type of system: ❑ Cesspool(s) D-90eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes J;j/No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name S i Vehicle License Number Company --- - 7. Location where contents were disposed.- Signature of Hauler Dal( hftp://www.mass.gov/dep/water/approvals/t5forms.htm4inspect t5form4.doc•06/03 System Pumping Record•Page 1 of 1