HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 145 BOSTON STREET 11/2/2022 <C\ Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4 �c
DEP has provided this form for use by local Boards of Health. The Systeii�umpi cor�tust
o the local Board of Health or other approving authority. p0
be submitted t PP 9
P �
A. Facility Information o�'�o�eP
Important:
When filling out 1. System Location:
forms on the
computer,use -
only the tab key Address
to move your Nam _
cursor-do not City/Town State Zip Code
use the return
key.
2. System Owner:
_�>�j c rr. A-dcc l
Name
Address(if different from location)
CityfTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons Sri
3. Type of system: ❑ Cesspool(s) 9--S"eptic Tank ❑ Tight Tank
❑ Other(describe): — - - —
4. Effluent Tee Filter present? �s ❑ No If yes, was it cleaned? Fol�yes ❑ No
5. Condition of System:
6. System Pumped By:
Name �T Vehicle License Number
Company ------
7. Locations where contents were disposed:
c. .
0 90 =�' -------
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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