HomeMy WebLinkAboutSeptic Pumping Slip - 176 VEST WAY 12/28/2015 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
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 the r,computer,use 176 VEST WAY
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:
PAULA KUSHNIR
Name
Address(if different from location)
City/Town State Zip Code
978-697-2415
Telephone Number
B. Pumping Record
1. Date of Pumping 10/14/15 2. Quantity Pumped: 1,500
Date Gallons
3. Type of system: ❑ Cesspool(s) On Septic Tank ❑ Tight Tank
F-1 Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? FN 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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