HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 130 HAY MEADOW ROAD 11/2/2022 Corpmonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS z�civ
System Pumping Record
-� Form 4
w �ty*DOVEH
DEP has provided this form for use by local Boards of Health. The System Pu ENT
be submitted to the local Board of Health or other approving authority. S EALTH pE
A. Facility Information
Important:
When filling out 1. System Location:
forms on the n ��/
computer,use 30 �° cad�J -------
only the tab key Address
to move our
y /Vo
cursor-do not City/Town State Zip Code
use the return
key.
2. System Owner:
ICI S-r-e-v,c" ni '
Name
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe): ---
4. Effluent Tee Filter present? [91res ❑ No If yes,was it cleaned? [?<es ❑ No
5. Condition of System:
6. System Pumped By: c
G./
Name Vehicle License Number
Company
7. Location where contents were disposed:
Via
Signature of Hauler ✓ Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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