HomeMy WebLinkAboutSeptic Pumping Slip - 44 SHERWOOD DRIVE 12/28/2015 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
w° System Pumping Record
Form 4
M
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 44 SHERWOOD DR
computer,use
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:
QLAURA KLIMAS
Name
_"Address(if different from location)
i
CitylTown State Zip Code
o ? c.
978-686-9455
Telephone Number
B. Pumping Record
1. Date of Pumping Date 10/01/15 1,500
2. Quantity Pumped: 1,500
3. Type of system: ❑ Cesspool(s) ❑■ Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? r0_1 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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