HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 87 HAY MEADOW ROAD 10/4/2021 ' AECEIVFt
Commonwealth of Massachusetts NpV 0 2 2o2t
City/Town of NORTH ANDOVER, MASSACHUSET „NOFNOtil-HANDOVEH
System Pumping Record HEALTH DEPARTMENT
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 ,,/
computer,use 9::Lj Ti'e-/) `j&tj�/ 120 A-
only the tab key Address
to move your A) 4 r,
cursor-do not City/Town State Zip Code
use the return
key-
2. System Owner:
Name
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
a-f)
1. Date of Pumping Date D S/ 2. Quantity Pumped: Gallonss
3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank
❑ Other(describe): �/ -- --
4. Effluent Tee Filter present? El Yes [? No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
QL
6. System Pumped By:
Name e Vehicle License Number
Company --- ----- --
7. Location where contents were disposed:
C,C s
cO 9�
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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