HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 2177 TURNPIKE 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.
A. Facility_ Information �cE�
Important: O
When filling out 1. System Location: O� P P 0\01
(orms on computer,use �/ a7 � Tu 2 ti jo
only the tab key Address &
to move your A,),o •(O`N� 00
cursor-do not City/Town State � Zip Code
use the return
key.
2. System Owner
-p-2 o m-e 240
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Quantity Pumped: Gallons
Date
3. Type of system.- ❑ Cesspool(s) �eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ErY�es ❑ No If yes. was it cleaned? 7 Yes ❑ No
5. Condition.of System:
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
C� .52_2
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record-Page 1 of 1