HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1444 SALEM STREET 11/2/2022 Commonwealth 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. itrC �\� t
A. Facility Information 2
Important:
When filling out 1. System Location: IyORfHEN�
forms on the �+
computer,use �] �YY1 7- .,.niN �,tTPAA
only the tab key Address
to move your )q rn, B V e-
cursor-do not 12
City/Tov 2 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 t
J e— 3 2. QuantityPumped: O'71'a
1. Date of Pumping Date p Gallons
3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank
❑ Other(describe): -
4. Effluent Tee Filter present? ❑ Yes <o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
2!—a
6. System Pumped By:
Name d / Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler Date
hftp://www.mass.gov/dep/water/approvals/t5forms.htm4inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1