HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 845 WINTER STREET 11/2/2022 Commonwealth of MassachusettscEwE�
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record �AOV ® 22o2z
-� Form 4 N i\,
cO�l�tj1� pEP�SMEN�
DEP has provided this form for use by local Boards of Health. The System PumptAbAVord 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 3 S r 7 r
computer,use
only the tab key Address
to move your �j e 7q rVC16 u Q.PL
cursor-do not City/Town State Zip Code
use the return
key_ 2 System Owner:
--
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 3 2. Quantity Pumped:
Date Gallons��
—�
3. Type of system: ❑ Cesspool(s) L9 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: CL
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler Date
hftp://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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