HomeMy WebLinkAboutSeptic Pumping Slip - 37 OLYMPIC LANE 12/28/2015 Commonwealth of Massachusetts
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City/Town of NORTH ANDOVER, MASSACHUSETTS
a w° System Pumping Record
I
^H Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
forms the
computer, use 36 OLYMPIC LANE
only the tab key Address
to move your N.ANDOVER MA 01845
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
rah JOANNE WESCOTT
Name
rertrn Address(if different from location)
'�Cityrrown State Zip Code
508-265-9952
Telephone Number
tf,J.
f t Ps
B. Pumping Record
1. Date of Pumping Date 08/04/15 2. Quantity Pumped: 1,000
Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes t❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System;
GOOD
6. System Pumped By;
ROGER ROBEY 7626AR
Name Vehicle License Number
SOUCY SEWER SERVICE INC
Company
7. Location where contents were disposed:
G.L.S.D.
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