HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1557 SALEM STREET 11/2/2022 < Corn' monwealth of Massachusetts
IFCity/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
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Form 4DEP has provided this form for use by local Boards of Health. The System Pumpin%i6��must
be submitted to the local Board of Health or other approving authority. p
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A. Facility Information �0
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CEP
Important:
When filling out 1. System Location:
forms on the S 7—
computer,use
only the tab key Address to move your N)d iQ n JO vc—rU �
cursor-do not City/Town State Zip Code
use the return
key.
2. System Owner:
�D6N �e- "cl.e 2
Name
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping �12- Quantity Pumped:
Date Gallonsr 0'd
3. Type of system: ❑ Cesspool(s) �eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
V-a o
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
Z -
Signature of Hauler Date
hftp://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc-06/03 System Pumping Record.Page 1 of 1