HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 55 RALEIGH TAVERN LANE 11/2/2022 \ Commonwealth of Massachusetts
19City/Town of NORTH ANDOVER, MASSACHUSETTS
Z System Pumping Record Nw 0 22022
Form 4
w�of NUFFpp'51 EN
DEP has provided this form for use by local Boards of Health. The System PurQM7 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 "��r�l `� f} ✓_�'2 AJ r`A"W�e_
only the tab key Address /1
to move your &)p -A Na(0 V-e 2- Al 4
cursor-do not Cityrrown State Zip Code
use the return
key.
2. System Owner.
-C_
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping bate-a 3 3�` 2 Quantity Pumped: Gatb^ �
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe).-
4. Effluent Tee Filter present? ❑ Yes ff No If yes. was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name cVehicle License Number
Company
7. Location where contents were disposed:
C� .5 �
9 -� 3 -ate
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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