HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 90 ABBOTT STREET 11/2/2022 Commonweaith of Massachusetts
City/Town of NORTH ANDOVER, MASSACH_USETTS
System Pumping Record
11 IV,
1 Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping keg oa6ust
be submitted to the local Board of Health or other approving authority. ^.,�� NpC
A. Facility Information ppFt�"
Important:
When filling out 1. System Location:
forms the / L C�
computer,
C/r,use F�
only the tab key Address
to move your A,)y -A A,4o ct c 2 _ 4
cursor-do not Cityrrown State Zip Code
use the return
key.
2. System Owner:
d.
Name
Address(if different from location)
cityrrom State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank
❑ Other(describe): _--
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
b-a
CL
6. System Pum�ped By:
'
Name Vehicle License Number
Company —
7. Location where contents were disposed:
XSZ
90 �
Signature of Hauler Date
hftp://www.mass.gov/dep/water/approvals/t5forrns.htm#inspect
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