HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 415 BOXFORD STREET 11/2/2022 Cornmonwealth 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.
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A. Facility Information
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2. System Owner:
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Name
Address(if different from location)
Cityffown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) [R Septic Tank ❑ Tight Tank
❑ Other(describe): -
4. Effluent Tee Filter present? [?'*Y"'es ❑ No if yes,was it cleaned? [j Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name # Vehicle License Number
Company------
7. Location where contents were disposed:
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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