HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 2177 TURNPIKE STREET 4/1/2024 (2) Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
3= System Pumping Record tioti°�
Form 4 eXN
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DEP has provided this form for use by local Boards of Health. The System Pumping Re��Ytf 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/ -// 7
computer,use c�
only the tab key Address y� �
to move your ,/�-}-4 - 7� Zt, ///)*6—.
cursor-do not City/Town 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---- --------- --
a�
1. Date of Pumping pate 2 Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe): — -—
4. Effluent Tee Filter present? �es ❑ No If yes,was it cleaned? [T'Y�es ❑ No
5. Condition of System
6. System Pumped By:
Name # Vehicle License Number
Company
7. .Location where contents were disposed:
Signature of Hauler Date
hftp://Www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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