HomeMy WebLinkAboutSeptic Pumping Slip - 545 JOHNSON STREET 12/28/2015 ;gZN- Commonwealth of Massachusetts
9TS�
City/Town of NORTH ANDOVER, MASSACHUSETTS I
System Pumping 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 Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer,use 545 JOHNSON ST
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:
QMARY DAVIS
Name
Address(if different from location)
Gity/Town State Zip Code
978-688-0715
Telephone Number
0J C.(c
Pumping Record
1. Date of Pumping Date 08/24/15 2• Quantity Pumped: 1,500
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? X 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
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