HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 87 HAY MEADOW ROAD 11/2/2022 1�
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
;w
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
Important:
When filling out 1. System Location:
forms on the OF NJ�PPptSMENt
computer,use
only the tab key Address HEP
to move your VV C,
cursor-do not Cityrrown State Zip Code
use the return
key.
2. System Owner:
dr
b A
Name
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record ---- _ - ---
1. Date of Pumping DJ b�"� a�` 2 Quantity Pumped: Gallo/r
3. Type of system: ❑ Cesspool(s) [RSeptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 9'110 If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of.System:
IZL
6. System Pumped
cBy:
, /
Name �T Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler Date
http:/Iwww.mass.gov/dep/water/approvals/t5forms.htm#inspect
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