HomeMy WebLinkAboutSeptic Pumping Slip - 1755 OSGOOD STREET 12/28/2015 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER. MASSACHUSETTS 1
a W System Pumping Record
Form 4
4A. s I
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 1755 OSGOOD STREET
computer,use
only the tab key Address 01845
to move your N.ANDOVER MA
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
rQ L-COM
Name
ran Address(if different from location)
City/Town State Zip Code
978-682-6936
Telephone Number
� � g & Pumping Record
06/09/15 1,500
1. Dafe of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) n Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Q 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.doc•06/03 System Pumping Record•Page 1 of 1