HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 835 CHESTNUT STREET 10/19/2021 Colrimonwealth of Massachusetts
City/Town of NORTH ANDOVER, 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 �. 3 /`! s3^µ4 7r S 7
computer,use
only the tab key Address
to move your yg a 1 4 pr"-,g e
cursor-do not
City/Town State Zip Code
use the return
key- 2- System Owner.
Name
tom+ Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record ------- -------
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 [�No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
0 0 d
6. System Pumped By:
Name
Vehicle License Number
Company —— -
7. Location where contents were disposed:
C .S
c.
signature of Hauler Date
hftp://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record-Page 1 of 1