HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 2177 TURNPIKE STREET 4/2/2024 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 Systen�oP mptng Record must
be submitted to the local Board of Health or other approving auth�[. -
A. Facility Information pQR
Important: erk
When filling out 1. System Location: pal
forms on the
computer,use
only the tab key Address
to move your Aj.
cursor-do not City/Town State Zip Code
use the return
key.
2. System Owner:
i e.- 4
Name
Address(rf different from location)
CitylTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped.
Date Gallon
3. Type of system: ❑ Cesspool(s) E?/Septic Tank ❑ Tight Tank
[] Other (describe): - - - -- -
4. Effluent Tee Filter present? Z<es ❑ No If yes, was it cleaned? 2Y"'es ❑ No
5. Condition of System:
6. System Pumped By:
Name t Vehicle License Number
Company — -----
7. Location where contents were disposed:
c,
Signature of Hauler Date i
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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