HomeMy WebLinkAboutSeptic Pumping Slip - 1094 SALEM STREET 12/9/2015 Commonwealth of Massachusetts �.
l
City/Town of NORTH ANDOVER, MASSACHU E'
System Pumping Record ��
Form 4 '
f
TO&N 0,r N 14 4 ANDOVER l
DEP has provided this form for use by local Boards of Health. The Sys m pilm'IRMvivitmus
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 r G: ct
only the tab key Address
to move your x cry? ,� ��/% /h-
cursor"do not
use the return Cityrrown State Zip Code
key. 2. System Owner:
l,:a Yx'1 a,I I e✓L
Name
F-1❑ Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ❑ ...,/ 2. Quantity Pumped: ll fi�
Date Gallons
3. Type of system: ❑ Cesspool(s) 2 Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Condition of System:
6. System Pumped By:
Ct
Name Vehicle License Number
Company
7. Location where contents were disposed:
. .
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms,htm#inspect
t5form4.doca 06/03 System Pumping Record-Page 1 of 1
i