HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 135 BOSTON STREET 11/2/2022 <n�\ Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
FY
Form 4 2101 ��Fa
DEP has provided this form for use by local Boards of Health. The System Pumping A� ord r ���o"I
be submitted to the local Board of Health or other approving authority. �NONG�PP(��M
A. Facility Information
Important:
When filling out 1. System Location:
forms the 13 S &-I ,L
computer,
r,use
only the tab key Address
to move your /Uo 95�71 �¢-
cursor-do not Cityrrown State Zip Code
use the return
key.
2. System Owner:
Name
Address(d different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
ta-a
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) D Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 3-No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name f Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Nauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm4inspect
t5form4.doc-06/03 System Pumping Record•Page 1 of 1