HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 428 WINTER STREET 11/2/2022 < Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS ov o �2p�1
System Pumping Record N tJpov�"
-� Form 4 �OWo Off'N��PA��MENS
DEP has provided this form for use by local Boards of Health. The System PumpQ ecord 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
computer,use -7
only the tab key Address
to move your 'f c��'L dip-W t` I'1'1. 4-
cursor-do not City/Town She Zip Code
use the return
key.
2. System Owner:
o nJ 'IF7>7 R-aL
Name
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping �a 4 �Quantity Pumped: Gains
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? 'es ❑ No If yes,was it cleaned? Ea'Yes ❑ No
5. Condition of System:
6. System Pumped By:
G I „l c_
Name Vehicle License Number
Company --- --
7. Locations where contents were disposed:
c91
Signature of Hauler Date
http://wvrw,mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record.Page 1 of 1