HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 2177 TURNPIKE STREET 4/1/2024 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'h16st
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location: BBB�.�
forms on the 1 17 J �o -mod"
computer,use
only the tab key Address M
to move your I J c afd 4tJR-ate /"Gi-o� &
cursor-do not City/Town State Zip Code
use the return
key.
2. System Owner:
-e ¢.e
Name
1 Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
a�
1. Date of Pumping Da /3 2. Quantity Pumped: Gallon
3. Type of system: ❑ Cesspool(s) PT"Septic Tank ❑ Tight Tank
❑ Other(describe): -
4. Effluent Tee Filter present? 19 es ❑ No If yes,was it cleaned? Yes ❑ No
5. Condition of System.-
6. System Pumped By:
st c
Name Vehicle License Number
Company -------
7. Location where contents were disposed:
- --- -
Signature of Hauler Date
http:l/www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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