HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 15 SAW MILL ROAD 4/10/2023 Cot'monwealth of Massachusetts
f9 City/Town of NORTH ANDOVER, MA SSACHUSETTS
R�%� SysteR.
msumpirg Record
Form 4,
DEP has provided this form for use by local.Boards of Health. The System Pumping Record must
be submitted to the local Beard of Health or other approving authority.
A,—Fac-ilityInformation -- y��
Important:
When filling out 1. System Location:
forms on the
computer,use
only the tab key Address y
to move your ) z — 0 - %
cursor-do not — State , Off,` P Zip Cod
use the return City/Town "1*
key. ,f4
2. System Owner:
NameC
tatra Address(if different from location)
CityfTown State Zip Code
Telephone Number
� B. Bumping Record --- --- -- _---- - .
1. Date of Pumping - -1 — -t3 2. Quantity Pumped: -
„F Gallons
3. Type of system: ❑ Cesspool(s) [+Septic Tank ❑ Tight Tank
❑ Other(describe): -- ---- --__---- -- ---
4. Efflueni Tee Filter present? Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Condition of System:
6. System Purnped By:
Name Vehicle Liccn sc Number
Company
Location where contents were disposed:
Signature of Hauler j Gata
httpJhvww.mass.gov.�/dep;water/approvals/t5forms-htm#inspect
t5form4.doc-06,03 System Pumping Record-Page 1 of 1