HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 835 CHESTNUT STREET 10/14/2020 Commonwealth 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 IF 3 S--
computer,use only the tab key Address `�
to move your A ).o C�Q"tL 04_,c �
cursor-do not City own State Zip Code
use the return
key.
2. System Owner:
�--
Name
Address(if different from location)
Cityrrown state Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping _a o Date 2 Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe): _---- — --
4. Effluent Tee Filter present? ❑ Yes 21"'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
CL --
6. System Pumped By:
Name Vehicle License Number
Company
7. Locationwhere contents were disposed:
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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