HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1634 SALEM STREET 11/2/2022 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 q l
Important: NAO O u 00,0k
When filling out 1. System Location: TH pN
forms on the
computer,use ST - ,.�nit`10PP
only the tab key Address
to move your IVb ,Q v clod e/L hl o
cursor-do not City/Town state Zip Code
use the return
key.
2. System Owner:
Wi9-2, 42 A- R CI R rn S
Name
Address(if different from location)
CitylToHn State Zip Code
Telephone Number
B. Pumping Record 1. Date of Pumping n
Date 2. Quantity Pumped: Gallons�
3. Type of system: ❑ Cesspool(s) E[ Septic Tank ❑ Tight Tank
❑ Other(describe): --- — _- -
4. Effluent Tee Filter present? ❑ Yes F
No If yes,was it cleaned? Yes ❑ No
5. Condition of System: n
6. System Pumped By: (�-
Name �T Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler 61Date
hftp://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record.Page 1 of 1